Minor injuries telemedicine

The Use of Patient-Facing Teleconsultations in the National Health Service: Scoping Review

BACKGROUND

The National Health Service (NHS) Long-Term Plan has set out a vision of enabling patients to access digital interactions with health care professionals within 5 years, including by video link.

OBJECTIVE

This review aimed to examine the extent and nature of the use of patient-facing teleconsultations within a health care setting in the United Kingdom and what outcome measures have been assessed.

METHODS

We conducted a systematic scoping review of teleconsultation studies following the Joanna Briggs Institute methodology. PubMed, Scopus, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were searched up to the end of December 2018 for publications that reported on the use of patient-facing teleconsultations in a UK health care setting.

RESULTS

The search retrieved 3132 publications, of which 101 were included for a full review. Overall, the studies were heterogeneous in design, in the specialty assessed, and reported outcome measures. The technology used for teleconsultations changed over time with earlier studies employing bespoke, often expensive, solutions. Two-thirds of the studies, conducted between 1995 and 2005, used this method. Later studies transitioned to Web-based commercial solutions such as Skype. There were five outcome measures that were assessed: (1) technical feasibility, (2) user satisfaction, (3) clinical effectiveness, (4) cost, (5) logistical and operational considerations. Due to the changing nature of technology over time, there were differing technical issues across the studies. Generally, teleconsultations were acceptable to patients, but this was less consistent among health care professionals. However, among both groups, face-to-face consultations were still seen as the gold standard. A wide range of clinical scenarios found teleconsultations to be clinically useful but potentially limited to more straightforward clinical interactions. Due to the wide array of study types and changes in technology over time, it is difficult to draw definitive conclusions on the cost involved. However, cost savings for health care providers have been demonstrated by the goal-directed implementation of teleconsultations. The integration of technology into routine practice represents a complex problem with barriers identified in funding and hospital reimbursement, information technologies infrastructure, and integration into clinicians' workflow.

CONCLUSIONS

Teleconsultations appear to be safe and effective in the correct clinical situations. Where offered, it is likely that patients will be keen to engage, although teleconsultations should only be offered as an option to support traditional care models rather than replace them outright. Health care staff should be encouraged and supported in using teleconsultations to diversify their practice. Health care organizations need to consider developing a digital technology strategy and implementation groups to assist health care staff to integrate digitally enabled care into routine practice. The introduction of new technologies should be assessed after a set period with service evaluations, including feedback from key stakeholders.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Real-time video telemedicine applications in the emergency department: a scoping review of literature

Objectives

To collect and synthesize the literature describing the use of real-time video-based technologies to provide support in the care of patients presenting to emergency departments.

Data Source

Six electronic databases were searched, including Medline, CINAHL, Embase, the Cochrane Database, DARE, and PubMed for all publications since the earliest date available in each database to February 2016.

Study Selection

Selected articles were full text articles addressing the use of telemedicine to support patient care in pre-hospital or emergency department settings. The search yielded 2976 articles for review with 11 studies eligible for inclusion after application of the inclusion and exclusion criteria. A scoping review of the selected articles was performed to better understand the different systems in place around the world and the current state of evidence supporting telemedicine use in the emergency department.

Conclusions

Telemedicine support for emergency department physicians is an application with significant potential but is still lacking evidence supporting improved patient outcomes. Advances in technology, combined with more attractive price-points have resulted in widespread interest and implementation around the world. Applications of this technology that are currently being studied include support for minor treatment centres, patient transfer decision-making, management of acutely ill patients and scheduled teleconsultations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of an off-the-shelf mobile telemedicine model in emergency department wound assessment and management

We examined the agreement between a videoconference-based evaluation and a bedside evaluation in the management of acute traumatic wounds in an emergency department. Adult and paediatric patients with acute wounds of various severities to the face, trunk and/or extremities presenting to the emergency department within 24 hours of injury were enrolled. Research assistants transmitted video images of the wound to an emergency physician using a laptop computer. The physician completed a standard wound assessment form before conducting a bedside evaluation and then completing a second assessment form. The primary outcome measure was wound length and depth. We also assessed management decision-making. A total of 173 wounds were evaluated. The correlation coefficient between video and bedside assessments was 0.96 for wound length. The mean difference between the lengths was 0.02 cm (SD 0.91). Management of the wound would have been the same in 94% of cases. The agreement on wound characteristics and wound management ranged from 84-100%. The highest correlation was 0.92 in suture material used and the lowest correlation was 0.64 in wound type. The ability of video images to distinguish between a minor and non-minor wound, and predicting the need for hospital management, had high degrees of sensitivity and specificity. The study showed that wound characteristics and management decisions appear to correlate well between video and bedside evaluations.

The introduction of a new consulting technology into the National Health Service (NHS) for Scotland

New technologies can change healthcare delivery. Cisco HealthPresence, an integrated platform that combines video, audio, and call center technology with medical information to create a virtual clinic experience, was piloted on emergency department patients. The aim was to assess primary care consultations. Patients were supported by an assistant. The doctor was remote from the patient and collected details and a recommended management plan. The same doctor re-examined the patient face-to-face. All patients completed a questionnaire about the experience. Key staff and a small sample of patients were interviewed. One hundred and five (N = 105) patients were included; 42% were given advice, 25% were prescribed analgesia, 26% were prescribed antibiotics, and 15% were x-rayed. There were early problems with the digital stethoscope. Doctors reported that the management plan changed in 7% of cases after seeing the patient. At least 90% of patients reported a positive experience. All patients and staff interviewed were positive. Staff found equipment to be valid and reliable; a concern was the inability to perform "hands on" examination. Telemedicine requires a change in the way of consulting and staff must be interested in using the technology to understand the differences. As one of the doctors said, "HealthPresence was a positive experience." Greater numbers would be required to validate key findings. As judged by clinicians, HealthPresence was successful and potentially safe for triage of unscheduled cases. Different types of staffing models need to be considered to ensure optimum use of health professionals. This study has shown that, despite some limitations, most HealthPresence consultations were found to be safe and appropriate. Further study of this consultation technology is required. HealthPresence has the potential to transform access to services for many patients, and to improve the effectiveness of delivery across a number of services.

Provision of telehealth to the Scottish Police College

Summary

A telemedicine service was established for the Scottish Police College with medical advice provided from the Aberdeen Royal Infirmary. Use of the service from November 2004 to February 2006 was audited. A total of 192 patients presented to the service during the 16-month study period. There were 97 teleconsultations. The remaining 95 patients (49%) were not seen by telemedicine due to technical problems. The complaints dealt with were 68% injuries and 32% minor illness ( n = 97). The outcome of the teleconsultation was: advice alone 76%; referral to a general practitioner 10%; and A&E referral 14% ( n = 97). The treatment advised was: over-the-counter medicine 85%; prescription 5%; and nil 10% ( n = 97). Even with a 24% connection rate, the service overall was perceived as beneficial and the Police College wished to continue to use the service, if the technology difficulties could be resolved.