Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study

Using a telemedicine-assisted airway model to improve the communication and teamwork of tracheal intubation during the coronavirus disease 2019 pandemic

INTRODUCTION

Isolated spaces impair communication and teamwork during tracheal intubation (TI) in suspected coronavirus disease 2019 patients. We thus aimed to evaluate the telemedicine-assisted airway model (TAM) to improve communication and teamwork during the pandemic.

METHODS

This two-stage prospective study included adult patients intubated in the emergency department of the National Taiwan University Hospital between 1 August 2020 and 31 July 2021. First, we randomised patients receiving TI in the standard setting into the conventional group (Con-G) and the isolation area into the isolation group (Iso-G). We evaluated the obstacles to communication and teamwork in an isolation scenario. Second, we developed the TAM to facilitate communication and teamwork between staff in separate spaces during TI and assigned patients to the TAM group (TAM-G). Communication and teamwork were evaluated using the Team Emergency Assessment Measure (TEAM). Subjective evaluations were conducted using a questionnaire administered to medical staff.

RESULTS

Eighty-nine patients were enrolled: 17, 34, and 38 in the Con-G, Iso-G, and TAM-G, respectively. The communication frequency (CF) of the Con-G and Iso-G was the highest and lowest, respectively. The CF of the TAM-G increased and approached that of the Con-G. The overall TEAM score was the highest in the Con-G and the lowest in the Iso-G, while the overall score in the TAM-G was comparable to that of the Con-G.

DISCUSSION

The TAM may improve communication and teamwork for TIs without compromising efficacy during the pandemic. This study was registered at ClinicalTrials.gov; registration numbers: NCT04479332 and NCT04591873.

Videolaryngoscopy in neonatal clinical care

Endotracheal intubation is a life-saving procedure for many newborns. Historically, it has been achieved by obtaining an airway view through the mouth via direct laryngoscopy. It is a skill that takes time and practice to achieve proficiency. Increasing evidence for the benefit of videolaryngoscopy in adults and the new development of technology has allowed videolaryngoscopy to become a reality in neonatal care. Studies have examined its use as both a technique to improve intubation safety and success, and as a training tool for those learning the skill in this vulnerable population. We present the current evidence for videolaryngoscopy in neonates in different settings where intubation may be required, in addition to exploring the challenges and practicalities of implementing this technique into clinical practice.

Characteristics and Effectiveness of Mobile- and Web-Based Tele-Emergency Consultation System between Rural and Urban Hospitals in South Korea: A National-Wide Observation Study

(1) Background: The government of South Korea has established a nationwide web- and mobile-based emergency teleconsultation network by designating urban and rural hospitals. The purpose of this study is to analyze the characteristics and effectiveness of the tele-emergency system in South Korea. (2) Methods: Tele-emergency consultation cases from May 2015 to December 2018 were analyzed in the present study. The definition of a tele-emergency in the present study is an emergency consultation between doctors in rural and urban hospitals via a web- and mobile-based remote emergency consultation system (RECS). Consultations through an RECS are grouped into three categories: medical procedure or treatment guidance, image interpretation, and transportation requests. The present study analyzed the characteristics of the tele-emergency system and the reduction in unnecessary transportation (RUT). (3) Results: A total of 2604 cases were analyzed in the present study from 2985 tele-emergency consultation cases. A total of 381 cases were excluded for missing data. Consultations for image interpretation were the most common in trauma cases (71.3%), while transfer requests were the most common in non-trauma cases (50.3%). Trauma patients were more frequently admitted to rural hospitals or discharged and followed up with at rural hospitals (20.3% vs. 40.5%) after consultations. In terms of disease severity, non-severe cases were statistically higher in trauma cases (80.6% vs. 59.4%; p < 0.001). The RUT was statistically highly associated with trauma cases (60.8% vs. 42.8%; p < 0.001). In an analysis that categorized cases by region, a statistically higher proportion of transportation was used in island regions (69.9% vs. 49.5%; p < 0.003). More RUT was associated with non-island regions (30.1% vs. 50.5%; p = 0.001). (4) Conclusions: The tele-emergency system had a great role in reducing unnecessary patient transportation in non-severe trauma cases and non-island rural area emergency cases. Further research is needed for a cost/benefit analysis and clinical outcomes.

Ressenti des médecins lors de la prise en charge des urgences vitales dans les centres de santé en Guyane

Introduction : Les urgences vitales sont fréquentes dans les centres de santé isolés guyanais. La population médicale est composée de médecins généralistes avec peu de formation en médecine d’urgence.

Méthodes : Nous avons réalisé une étude descriptive au moyen d’un questionnaire diffusé à l’aide d’une mailing liste de 310 contacts de médecins ayant travaillé dans les centres délocalisés de prévention et de soins (CDPS) depuis les années 2010 à 2019.

Résultats : Nous avons obtenu 90 réponses sur 310 (29 %) et analysé 87 (28 %). La majorité des médecins était des généralistes (72 %) de moins de 40 ans (69 %) sans formation de médecine d’urgence (76 %). Les urgences majoritairement rencontrées étaient les comas et les polytraumatisés ainsi que les urgences gynéco-obstétricales. La majorité des médecins ont rapporté avoir été inconfortables durant ces prises en charge (67 %). La relation avec le service d’aide médicale urgente (Samu) a été jugée majoritairement adaptée (93 %). L’aide apportée par l’équipe paramédicale des CDPS était jugée correcte dans 49 % et excellente dans 48 % des cas. Plus d’un médecin sur cinq (21 %) a déclaré ne pas vouloir renouveler son contrat en CDPS du fait du vécu des urgences vitales. Afin d’améliorer la prise en charge des patients graves, les médecins sont favorables à la présence de fiches réflexes (87 %), à la formation en préaffectation sur mannequin (75 %), à de courtes formations aux déchoquages par des médecins urgentistes (67 %), à des alternatives à l’intubation orotrachéale telles que des dispositifs supraglottiques (68 %) et à l’aide guidée par la télémédecine (30 %).

Conclusion : Ce travail révèle une importante souffrance des médecins face aux difficultés vécues dans la prise en charge des urgences vitales. Afin de répondre aux problématiques soulevées par cette étude, la majorité des mesures d’amélioration évoquées dans ce travail sont en cours de mise en place depuis la fin de l’année 2019.

Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review

OBJECTIVE

Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization.

METHODS

We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization.

RESULTS

We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies.

CONCLUSIONS

Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.

Teleguidance Technology for Endotracheal Intubation: A Scoping Review

Supplemental Digital Content is available in the text.

OBJECTIVES:

Teleguidance facilitated intubation has recently reemerged during the coronavirus disease 2019 pandemic as a strategy to provide expert airway management guidance and consultation to practitioners in settings where such expertise is not readily available onsite or in-person. We conducted a scoping review to provide a synthesis of the available literature on teleguidance facilitated intubation. Specifically, we aimed to evaluate the feasibility, safety, and efficacy of teleguidance facilitated intubation given existing technology.

DATA SOURCES:

A librarian-assisted search was performed using three primary electronic medical databases from January 2000 to November 2020.

STUDY SELECTION:

Articles that reported outcomes focused on implementing or evaluating the performance of teleguidance facilitated intubation were included.

DATA EXTRACTION:

Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

DATA SYNTHESIS:

Of 255 citations identified, 17 met eligibility criteria. Studies included prospective investigations and proof of technology reports. These studies were performed in clinical and simulation environments. Five of the prospective investigations that examined time to intubation and intubation success rates. Multiple different commercially available and noncommercial teleconference software systems were used in these studies.

CONCLUSIONS:

There is a limited body of literature evaluating the feasibility, safety, and efficacy of teleguidance facilitated intubation. Based on the studies available that examined a variety of technologies within simulation and clinical environments, teleguidance facilitated intubation appears to be feasible, safe, and efficacious. Given the exponential growth in the use of telemedicine technology during the coronavirus disease 2019 pandemic and the evidence supporting teleguidance facilitated intubation, there is a need to critically evaluate the most effective mechanisms to integrate and optimize these technologies across diverse practice settings.

Pilot Paramedic Survey of Benefits, Risks, and Strategies for Pediatric Prehospital Telemedicine

OBJECTIVE

A national survey found prehospital telemedicine had potential clinical applications but lacked provider opinion on its use for pediatric emergency care. We aimed to (1) estimate prehospital telemedicine use, (2) describe perceived benefits and risks of pediatric applications, and (3) identify preferred utilization strategies by paramedics.

METHODS

We administered a 14-question survey to a convenience sample of 25 Massachusetts paramedics attending a regional course in 2018. Volunteer participants were offered a gift card. We compared respondents to a state database for sample representativeness. We present descriptive statistics and summarize qualitative responses.

RESULTS

Twenty-five paramedics completed the survey (100% response); 23 (96%) were male, 21 (84%) 40 years or older, and 23 (92%) in urban practice. Respondents were older and more experienced than the average Massachusetts paramedic. Few had used prehospital telemedicine for patients younger than 12 years (8%; 95% confidence interval, 10-26%). Potential benefits included paramedic training (80%), real-time critical care support (68%), risk mitigation (68%), patient documentation (72%), decision support for hospital team activation (68%), and scene visualization (76%). Time delays from telemedicine equipment use (76%) and physician consultation (64%), broadband reliability (52%), and cost (56%) were potential risks. Respondents preferred video strategies for scene visualization, physician-assisted assessment and care. More respondents felt pediatric telemedicine applications would benefit rural/suburban settings than urban ones.

CONCLUSIONS

Paramedics reported prehospital telemedicine is underutilized for children but identified potential benefits including provider telesupport, training, situational awareness, and documentation. Concerns included transportation delays, cost, and broadband availability. Video was preferred for limited pediatric exposure settings. These results inform which telemedicine applications and strategies paramedics favor for children.

Characteristics of U.S. Acute Care Hospitals That Have Implemented Telemedicine Critical Care

Supplemental Digital Content is available in the text.

OBJECTIVES:

Telemedicine critical care is associated with improved efficiency, quality, and cost-effectiveness. As of 2010, fewer than 5% of U.S. hospitals had telemedicine critical care, and fewer than 10% of ICU beds were covered. We evaluated recent telemedicine critical care implementation and bed coverage rates in the United States and compared characteristics of hospitals with and without telemedicine critical care.

DESIGN:

Cross-sectional study of 2018 American Hospital Association Annual Survey Database.

SETTING:

U.S. hospitals.

PATIENTS:

None.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We obtained data regarding telemedicine critical care implementation, ICU capability (defined as ≥ 1 ICU bed), other hospital characteristics, and the Herfindahl-Hirschman Index, a measure of ICU market competition based on hospital referral regions. Among 4,396 hospitals (response rate 71%), 788 (17.9%) had telemedicine critical care, providing potential coverage to 27,624 (28% of total) ICU beds. Among 306 hospital referral regions, 197 (64%) had a respondent hospital with telemedicine critical care. Telemedicine critical care implementation was associated with being a nonprofit (odds ratio, 7.75; 95% CI, 5.18–11.58) or public (odds ratio, 4.16 [2.57–6.73]) compared with for-profit hospital; membership in a health system (odds ratio, 3.83 [2.89–5.08]; stroke telemedicine presence (odds ratio, 6.87 [5.35–8.81]); ICU capability (odds ratio, 1.68 [1.25–2.26]); and more competitive ICU markets (odds ratio per 1,000-point decrease in Herfindahl-Hirschman Index 1.11 [1.01–1.22]). Notably, rural critical access hospitals had lower odds of telemedicine critical care implementation (odds ratio, 0.49 [0.34–0.70]). Teaching status, geographic region, and rurality were not associated with telemedicine critical care implementation.

CONCLUSIONS:

About one fifth of respondent hospitals had telemedicine critical care by 2018, providing potential coverage of nearly one third of reported ICU beds. This represents a substantial increase in telemedicine critical care implementation over the last decade. Future expansion to include more rural hospitals that could benefit most may be aided by addressing hospital financial and market barriers to telemedicine critical care implementation.

Rural and Remote Intubations in an Australian Air Medical Retrieval Service: A Retrospective Cohort Study

OBJECTIVE

Critically unwell patients in rural and remote areas of Queensland, Australia, often require airway management with rapid sequence intubation before retrieval to a tertiary center. Retrieval Services Queensland coordinate retrievals and support rural hospitals, including via telehealth. This study compared the demographics of patients intubated by a retrieval team including a LifeFlight Retrieval Medicine doctor with those intubated by the local hospital team.

METHODS

This was a retrospective cohort study of patients intubated in hospitals in Queensland, Australia, requiring subsequent air medical retrieval between January and December 2019. The data collected included the time of day, mission priority, geographic location, diagnosis, and failure/assistance with intubation. Descriptive statistics were complemented by regression analyses.

RESULTS

In 2019, 684 patients were intubated in hospitals in Queensland, Australia, requiring air medical retrieval by a team including a LifeFlight Retrieval Medicine doctor. One hundred thirty-one (19.2%) were intubated by the retrieval team, and 553 (80.8%) were intubated by the hospital team. In the most rural and remote areas, 64 (43.2%) of the patients were intubated by the retrieval team compared with 84 (56.8%) by the hospital team.

CONCLUSION

A retrieval team is more likely to intubate patients in remote hospitals in Queensland, Australia. Remote hospitals should be given preference for dispatch of the retrieval team for assistance with critical patients.

Telehealth Availability in US Hospitals in the Face of the COVID-19 Pandemic

BACKGROUND

Telehealth is likely to play a crucial role in treating COVID-19 patients. However, not all US hospitals possess telehealth capabilities. This brief report was designed to explore US hospitals' readiness with respect to telehealth availability. We hope to gain deeper insight into the factors affecting possession of these valuable capabilities, and how this varies between rural and urban areas.

METHODS

Based on 2017 data from the American Hospital Association survey, Area Health Resource Files and Medicare cost reports, we used logistic regression models to identify predictors of telehealth and eICU capabilities in US hospitals.

RESULTS

We found that larger hospitals (OR(telehealth) = 1.013; P < .01) and system members (OR(telehealth) = 1.55; P < .01) (OR(eICU) = 1.65; P < .01) had higher odds of possessing telehealth and eICU capabilities. We also found evidence suggesting that telehealth and eICU capabilities are concentrated in particular regions; the West North Central region was the most likely to possess capabilities, given that these hospitals had higher odds of possessing telehealth (OR = 1.49; P < .10) and eICU capabilities (OR = 2.15; P < .05). Rural hospitals had higher odds of possessing telehealth capabilities as compared to their urban counterparts, although this relationship was marginally significant (OR = 1.34, P < .10).

CONCLUSIONS

US hospitals vary in their preparation to use telehealth to aid in the COVID-19 battle, among other issues. Hospitals' odds of possessing the capability to provide such services vary largely by region; overall, rural hospitals have more widespread telehealth capabilities than urban hospitals. There is still great potential to expand these capabilities further, especially in areas that have been hard hit by COVID-19.

Feasibility Evaluation of Commercially Available Video Conferencing Devices to Technically Direct Untrained Nonmedical Personnel to Perform a Rapid Trauma Ultrasound Examination

Introduction: Point-of-care ultrasound (POCUS) is a rapidly expanding discipline that has proven to be a valuable modality in the hospital setting. Recent evidence has demonstrated the utility of commercially available video conferencing technologies, namely, FaceTime (Apple Inc, Cupertino, CA, USA) and Google Glass (Google Inc, Mountain View, CA, USA), to allow an expert POCUS examiner to remotely guide a novice medical professional. However, few studies have evaluated the ability to use these teleultrasound technologies to guide a nonmedical novice to perform an acute care POCUS examination for cardiac, pulmonary, and abdominal assessments. Additionally, few studies have shown the ability of a POCUS-trained cardiac anesthesiologist to perform the role of an expert instructor. This study sought to evaluate the ability of a POCUS-trained anesthesiologist to remotely guide a nonmedically trained participant to perform an acute care POCUS examination. Methods: A total of 21 nonmedically trained undergraduate students who had no prior ultrasound experience were recruited to perform a three-part ultrasound examination on a standardized patient with the guidance of a remote expert who was a POCUS-trained cardiac anesthesiologist. The examination included the following acute care POCUS topics: (1) cardiac function via parasternal long/short axis views, (2) pneumothorax assessment via pleural sliding exam via anterior lung views, and (3) abdominal free fluid exam via right upper quadrant abdominal view. Each examiner was given a handout with static images of probe placement and actual ultrasound images for the three views. After a brief 8 min tutorial on the teleultrasound technologies, a connection was established with the expert, and they were guided through the acute care POCUS exam. Each view was deemed to be complete when the expert sonographer was satisfied with the obtained image or if the expert sonographer determined that the image could not be obtained after 5 min. Image quality was scored on a previously validated 0 to 4 grading scale. The entire session was recorded, and the image quality was scored during the exam by the remote expert instructor as well as by a separate POCUS-trained, blinded expert anesthesiologist. Results: A total of 21 subjects completed the study. The average total time for the exam was 8.5 min (standard deviation = 4.6). A comparison between the live expert examiner and the blinded postexam reviewer showed a 100% agreement between image interpretations. A review of the exams rated as three or higher demonstrated that 87% of abdominal, 90% of cardiac, and 95% of pulmonary exams achieved this level of image quality. A satisfaction survey of the novice users demonstrated higher ease of following commands for the cardiac and pulmonary exams compared to the abdominal exam. Conclusions: The results from this pilot study demonstrate that nonmedically trained individuals can be guided to complete a relevant ultrasound examination within a short period. Further evaluation of using telemedicine technologies to promote POCUS should be evaluated.

Use of a Smartphone-Based Augmented Reality Video Conference App to Remotely Guide a Point of Care Ultrasound Examination

Reports on the use of various smartphone-based video conference applications to guide point-of-care ultrasound (POCUS) examinations in resource-limited settings have been described. However, the use of an augmented reality-enabled smartphone video conference application in this same manner has not been described. Presented is a case in which such as application was used to remotely guide a point of care ultrasound examination.

The Association Between Telemedicine and Emergency Department (ED) Disposition: A Stepped Wedge Design of an ED-Based Telemedicine Program in Critical Access Hospitals

PURPOSE

To study the relationship between the availability and activation of emergency department-based telemedicine (teleED) and patient disposition in Critical Access Hospitals (CAHs).

METHODS

A non randomized stepped wedge design examined 133,396 ED visits in 15 CAHs that subscribe to a single teleED provider. Data were available for at least 12 months prior to teleED implementation and at least 12 months of post-implementation. Primary analyses were conducted using multinomial logistic regression models with teleED availability (indicator of post-teleED implementation period) and activation (indicator of utilization of teleED service) predicting discharge disposition adjusting for age, sex, and clinical diagnosis.

RESULTS

Patients for whom teleED was activated were more likely to be transferred [adjusted odds ratio (aOR) = 12.04; 95% confidence interval (CI), 10.97-13.21] and more likely to be admitted to the local hospital (aOR = 3.23; 95% CI, 2.84-3.67) than to be routinely discharged. This pattern was confirmed for patients presenting with chest pain, mental illness, and injury/poisoning. However, in the period following teleED implementation, patients presenting to EDs after telemedicine was available, but not necessarily utilized, were less likely to be admitted to the local hospital (aOR = 0.79; 95% CI, 0.76-0.82) than to be routinely discharged.

CONCLUSIONS

Telemedicine availability in CAH EDs is associated with a higher likelihood of routine discharges from the ED possibly due to changes in care associated with teleED implementation. The relationship between teleED use and disposition may be related to selection in activating teleED for cases more likely to require hospital inpatient care.

Use of Telemedicine to Improve Neonatal Resuscitation

Most newborn infants do well at birth; however, some require immediate attention by a team with advanced resuscitation skills. Providers at rural or community hospitals do not have as much opportunity for practice of their resuscitation skills as providers at larger centers and are, therefore, often unable to provide the high level of care needed in an emergency. Education through telemedicine can bring additional training opportunities to these rural sites in a low-resource model in order to better prepare them for advanced neonatal resuscitation. Telemedicine also offers the opportunity to immediately bring a more experienced team to newborns to provide support or even lead the resuscitation. Telemedicine can also be used to train and assist in the performance of emergent procedures occasionally required during a neonatal resuscitation including airway management, needle thoracentesis, and umbilical line placement. Telemedicine can provide unique opportunities to significantly increase the quality of neonatal resuscitation and stabilization in rural or community hospitals.

Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study

BACKGROUND

Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs.

INTRODUCTION

The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs.

MATERIALS AND METHODS

This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital.

RESULTS

Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy.

CONCLUSIONS

Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients

BACKGROUND

Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes.

OBJECTIVES

This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota.

METHODS

Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality.

RESULTS

Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.