Management of critically ill patients in austere environments: good clinical practice by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has developed a good clinical practice to address the challenges of treating critically ill patients in resource-limited austere environments, exacerbated by recent pandemics, natural disasters, and conflicts. The methodological approach was based on a literature review and a modified Delphi method, which involved blind voting and consensus evaluation using a Likert scale. This process was conducted over two rounds of online voting. The document covers six critical topics: the overall impact of austere conditions on critical care, airway management, analgesia, bleeding control, vascular access, and medical devices and equipment. In these settings, it is vital to apply basic care techniques flexibly, focusing on immediate bleeding control, airway management, and hypothermia treatment to reduce mortality. For airway management, rapid sequence intubation with ketamine for sedation and muscle relaxation is suggested. Effective pain management involves a multimodal approach, including patient-controlled analgesia by quickly acting safe drugs, with an emphasis on ethical palliative care when other options are unavailable. Regarding hemorrhage, military-derived protocols like Tactical Combat Casualty Care significantly reduced mortality and influenced the development of civilian bleeding control devices. Establishing venous access is crucial, with intraosseous access as a swift option and central venous access for complex cases, ensuring aseptic conditions. Lastly, selecting medical equipment that matches the specific logistical and medical needs is essential, maintaining monitoring standards and considering advanced diagnostic tools like point-of-care ultrasounds. Finally, effective communication tools for coordination and telemedicine are also vital.

Civilian and Military Medical School Graduates' Readiness for Deployment: Areas of Strength and Opportunities for Growth

INTRODUCTION

Past research has examined civilian and military medical schools' preparation of physicians for their first deployment. Most recently, our research team conducted a large-scale survey comparing physicians' perceptions of their readiness for their first deployment. Our results revealed that military medical school graduates felt significantly more prepared for deployment by medical school than civilian medical school graduates. In order to further investigate these results and deepen our understanding of the two pathways' preparation of military physicians, this study analyzed the open-ended responses in the survey using a qualitative research design.

MATERIALS AND METHODS

We used a descriptive phenomenological design to analyze 451 participants' open-ended responses on the survey. After becoming familiar with the data, we coded the participants' responses for meaningful statements. We organized these codes into major categories, which became the themes of our study. Finally, we labeled each of these themes to reflect the participants' perceptions of how medical school prepared them for deployment.

RESULTS

Four themes emerged from our data analysis: (1) Civilian medical school equipped graduates with soft skills and medical knowledge for their first deployment; (2) Civilian medical school may not have adequately prepared graduates to practice medicine in an austere environment to include the officership challenges of deployment; (3) Military medical school prepared graduates to navigate the medical practice and operational aspects of their first deployment; and (4) Military medical school may not have adequately prepared graduates for the realism of their first deployment.

CONCLUSIONS

Our study provided insight into the strengths and areas for growth in each medical school pathway for military medical officers. These results may be used to enhance military medical training regardless of accession pathway and increase the readiness of military physicians for future large-scale conflicts.

Evaluation of Telemedicine Support for Medics from the Perspective of Course Instructors

INTRODUCTION

Health services in the theater/district areas often contain difficulties. Although telemedicine has a huge potential to support medics in the area, there are challenges as well. Our aim is to evaluate the telemedicine support that can be provided to the medics from the perspective of course instructors.

MATERIALS AND METHODS

Our study was carried out in The University of Health Sciences, Türkiye. All of the instructors of a medic course were asked to fill a 13-question questionnaire and Likert-type scale, sent via e-mail. Among 79 instructors, 71 of them (55 physicians, 16 nonphysicians) responded and were included in the study. The distributions of the categorical variables in the groups were analyzed with the Pearson Chi-square.

RESULTS

Of the 71 participants, 37 (52.11%) stated that there is a need for legal and ethical regulations for telemedicine (medical liability, malpractice, obtaining consent from the casualties, civilians, cross border missions, and rank-related problems) and patients' rights, additionally, to clarify the responsibilities of the doctors giving telemedicine support and the medics in the area. It was observed that physicians' and nonphysician group's opinions about the telepsychotherapy were statistically significantly different (χ2 = 8.675, P = .013).

CONCLUSIONS

Most of the instructors believed that telemedicine could carry the knowledge and skills of specialist physicians to the field of operation. Access to high-quality health services in a short time through telemedicine support can increase the courage and commitment of the personnel. It is thought that with telemedicine, medics will not feel alone in the field, their worries about making wrong decisions will decrease, and their knowledge and skills will increase. Participants were particularly concerned about who will be held responsible for problems arising from interventions carried out using telemedicine, and strict legal and medical regulations are needed.

Harnessing technology for infectious disease response in conflict zones: Challenges, innovations, and policy implications

Epidemic outbreaks of infectious diseases in conflict zones are complex threats to public health and humanitarian activities that require creativity approaches of reducing their damage. This narrative review focuses on the technology intersection with infectious disease response in conflict zones, and complexity of healthcare infrastructure, population displacement, and security risks. This narrative review explores how conflict-related destruction is harmful towards healthcare systems and the impediments to disease surveillance and response activities. In this regards, the review also considered the contributions of technological innovations, such as the improvement of epidemiological surveillance, mobile health (mHealth) technologies, genomic sequencing, and surveillance technologies, in strengthening infectious disease management in conflict settings. Ethical issues related to data privacy, security and fairness are also covered. By advisement on policy that focuses on investment in surveillance systems, diagnostic capacity, capacity building, collaboration, and even ethical governance, stakeholders can leverage technology to enhance the response to infectious disease in conflict settings and, thus, protect the global health security. This review is full of information for researchers, policymakers, and practitioners who are dealing with the issues of infectious disease outbreaks in conflicts worn areas.

Tele-Critical Care Support Outside the Intensive Care Unit

Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.

Telemedicine for emergency patient rescue

PURPOSE OF REVIEW

This article summarizes recent developments in the application of telemedicine, specifically tele-critical care (TCC), toward enhancing patient care during various types of emergencies and patient rescue scenarios when there are limited resources in terms of staff expertise (i.e., knowledge, skills, and abilities), staffing numbers, space, and supplies due to patient location (e.g., a non-ICU bed, the emergency department, a rural hospital) or patient volume as in pandemic surges.

RECENT FINDINGS

The COVID-19 pandemic demonstrated the need for rapidly scalable and agile healthcare delivery systems. During the pandemic, clinicians and hospital systems adopted telemedicine for various applications. Taking advantage of technological improvements in cellular networks and personal mobile devices, and despite the limited outcomes literature to support its use, telemedicine was rapidly adopted to address the fundamental challenge of exposure in outpatient settings, emergency departments, patient follow-up, and home-based monitoring. A critical recognition was that the modality of care (e.g., remote vs. in-person) was less important than access to care, regardless of the patient outcomes. This fundamental shift, facilitated by policies that followed emergency declarations, provided an opportunity to maintain and, in many cases, expand and improve clinical practices and hospital systems by bringing expertise to the patient rather than the patient to the expertise. In addition to using telemedicine to maintain patient access to healthcare, TCC was harnessed to provide local clinicians, forced to manage critically ill patients beyond their normal scope of practice or experience, access to remote expertise (physician, nursing, respiratory therapist, pharmacist). These practices supported decades of literature from the telemedicine community describing the effectiveness of telemedicine in improving patient care and the many challenges defining its value.

SUMMARY

In this review, we summarize numerous examples of innovative care delivery systems that have utilized telemedicine, focusing on 'mobile' TCC technology solutions to effectively deliver the best care to the patient regardless of patient location. We emphasize how a 'paradigm of better' can enhance the entirety of the healthcare system.

Secure app-based secondary healthcare clinical decision support to deployed forces in the UK Defence Medical Services

BACKGROUND

Modern instant messaging systems facilitate reach-back medical support for Defence Medical Services (DMS) by connecting deployed clinicians to remote specialists. The mobile app Pando (Forward Clinical, UK) has been used for this purpose by the DMS via the 'Ask Advice' function. We aimed to investigate the usage statistics for this technology in its first 1000 days to better understand its role in the DMS.

METHODS

An observational study was undertaken using metadata extracted from the prospective database within the application server for clinical queries between June 2019 and February 2022. These data included details regarding number and name of specialties, timings, active users per day and the number of conversations.

RESULTS

There were 29 specialties, with 298 specialist users and 553 requests for advice. The highest volume of requests were for trauma and orthopaedics (n=116; 21.0%), ear, nose and throat (n=67; 12.1%) and dermatology (n=50; 9.0%). There was a median of 164 (IQR 82-257) users logged in per day (range 2-697). The number of requests during each day correlated with the number of users on that day (r=0.221 (95% CI 0.159 to 0.281); p<0.001). There were more daily users on weekdays than weekends (215 (IQR 123-277) vs 88 (IQR 58-121), respectively; p<0.001). For the top 10 specialties, the median first response time was 9 (IQR 3-42) min and the median time to resolution was 105 (IQR 21-1086) min.

CONCLUSION

In the first 1000 days of secure app-based reach-back by the DMS there have been over 500 conversations, responded to within minutes by multiple specialists. This represents a maturing reach-back capability that may enhance the force multiplying effect of defence healthcare while minimising the deployed 'medical footprint'. Further discussions should address how this technology can be used to provide appropriately responsive clinical advice within DMS consultant job-planned time.

Clustering Research Proposal Submissions to Understand the Unmet Needs of Military Clinicians

INTRODUCTION

The Advanced Medical Technology Initiative (AMTI) program solicits research proposals for technology demonstrations and performance improvement projects in the domain of military medicine. Advanced Medical Technology Initiative is managed by the U.S. Army Telemedicine and Advanced Technology Research Center (TATRC). Advanced Medical Technology Initiative proposals span a wide range of topics, for example, treatment of musculoskeletal injury, application of virtual health technology, and demonstration of medical robots. The variety and distribution of central topics in these proposals (problems to be solved and technological solutions proposed) are not well characterized. Characterizing this content over time could highlight over- and under-served problem domains, inspire new technological applications, and inform future research solicitation efforts.

METHODS AND MATERIALS

This research sought to analyze and categorize historic AMTI proposals from 2010 to 2022 (n = 825). The analysis focused specifically on the "Problem to Be Solved" and "Technology to Demonstrated" sections of the proposals, whose categorizations are referred to as "Problem-Sets" and Solution-Sets" (PS and SS), respectively. A semi-supervised document clustering process was applied independently to the two sections. The process consisted of three stages: (1) Manual Document Annotation-a sample of proposals were manually labeled along each thematic axis; (2) Clustering-semi-supervised clustering, informed by the manually annotated sample, was applied to the proposals to produce document clusters; (3) Evaluation and Selection-quantitative and qualitative means were used to evaluate and select an optimal cluster solution. The results of the clustering were then summarized and presented descriptively.

RESULTS

The results of the clustering process identified 24 unique PS and 20 unique SS. The most prevalent PS were Musculoskeletal Injury (12%), Traumatic Injury (11%), and Healthcare Systems Optimization (11%). The most prevalent SS were Sensing and Imaging Technology (27%), Virtual Health (23%), and Physical and Virtual Simulation (11.5%). The most common problem-solution pair was Healthcare Systems Optimization-Virtual Health, followed by Musculoskeletal Injury-Sensing and Imaging Technology. The analysis revealed that problem-solution-set co-occurrences were well distributed throughout the domain space, demonstrating the variety of research conducted in this research domain.

CONCLUSIONS

A semi-supervised document clustering approach was applied to a repository of proposals to partially automate the process of document annotation. By applying this process, we successfully extracted thematic content from the proposals related to problems to be addressed and proposed technological solutions. This analysis provides a snapshot of the research supply in the domain of military medicine over the last 12 years. Future work should seek to replicate and improve the document clustering process used. Future efforts should also be made to compare these results to actual published work in the domain of military medicine, revealing differences in demand for research as determined by funding and publishing decision-makers and supply by researchers.

Military Doctors' and Nurses' Perceptions of Telemedicine and the Factors Affecting Use Intention

Purpose: This study investigated military doctors' and nurses' perceptions of telemedicine and the factors influencing their intention to use it based on the unified theory of acceptance and use of technology. Method: This study adopted a questionnaire-based, cross-sectional descriptive approach. It used a web questionnaire for data collection over a 5-week period, starting in June 2021. Results: A total of 72.6% of participants indicated that telemedicine is required in the military. The intention to use telemedicine was significantly higher among women, younger individuals (<30 years), and military nurses. In addition, factors such as voluntariness of use, performance expectancy, social influence, and facilitating conditions positively affected the intention to use telemedicine. Conclusions: To improve military doctors' and nurses' use and understanding of telemedicine, consensus must be reached regarding its use in military contexts. Discussions that incorporate opposing views should be encouraged as well. Moreover, the voluntariness of use significantly affected respondents' intention to use telemedicine. There is an urgent need, therefore, for in-depth analyses of the various factors associated with voluntariness of use of telemedicine; the resulting insights could be used to encourage military doctors and nurses to adopt telemedicine. Finally, along with promoting the use of smartphones for medical consultation among military personnel, military nurses' role should be extended to include health consultation using smartphones. This could promote the active use of telemedicine in military nursing, which could contribute to health promotion among military personnel.

Applying a Military Teleophthalmology Mobile App in a Noncombat Emergent Care Setting

INTRODUCTION

Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting.

MATERIALS AND METHODS

We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record.

RESULTS

From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record.

CONCLUSIONS

Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.

Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict with Near-Peer Adversaries

In the past 20 years of the Global War on Terror, the US has seen substantial improvements in its system of medical delivery in combat. However, throughout that conflict, enemy forces did not have parity with the weaponry, capability, or personnel of the US and allied forces. War against countries like China and Russia, who are considered near-peer adversaries in terms of capabilities, will challenge battlefield medical care in many different ways. This article reviews the experience of a medical team, Global Surgical and Medical Support Group, that has been providing assistance, training, medical support, and surgical support to Ukraine since the Russian invasion began in February 2022. The team has extensive experience in medicine, surgery, austere environments, conflict zones, and building partner nation capacities. This article compares and contrasts the healthcare systems of this war against the systems used during the Global War on Terror. The lessons learned here could help the US anticipate challenges and successfully plan for the provision of medical care in a future conflict against an adversary with capabilities close to its own.

Infectious Disease Teleconsultation to the Deployed U.S. Military From 2017-2022

INTRODUCTION

The ADvanced VIrtual Support for OpeRational Forces (ADVISOR) program is a synchronous telemedicine system developed in 2017 to provide 24/7 remote expert support to U.S. Military and NATO clinicians engaged in medical care in austere locations. Infectious disease (ID) remains the highest consulted service since 2018 and is currently staffed by 10 adult and pediatric ID physicians within the Military Health System. We conducted a retrospective review of the ID ADVISOR calls between 2017 and 2022 to identify trends and better prepare military ID physicians to address urgent ID consultations in overseas settings.

METHODS

Health records of the ID consultations between July 2017 and January 2022 were reviewed for local caregiver and patient demographics, case descriptions, consultant recommendations, and outcomes. A "not research" determination was made by the Brooke Army Medical Center Human Research Protections Office.

RESULTS

ID physicians received 57 calls for 60 urgent patient consultations. Most calls were from countries in the Middle East or in Southwest Asia (United States Central Command (USCENTCOM)), followed by countries in Africa (United States Africa Command (USAFRICOM)). The majority of patients were active duty U.S. Military and were generally male with median age of 25 years. All consults involved an initial phone consultation and 30% continued over email. Ninety percent of the calls were initiated by physicians, and the median time from injury or illness-onset to consult was 3 days. Seventy percent of the consult questions involved treatment and further diagnostics, but one-third of cases required assistance with management of disease prevention. Multidrug-resistant or nosocomial infections, animal or bite exposure, malaria and malaria prevention, febrile illness, and blood-borne pathogen exposure accounted for 63% of the consults. Collaboration with other specialties took place in a minority of cases, and follow-up contact was recommended 20% of the time. Most recommendations involved adjusting drug regimens or further testing. Medical evacuation was only recommended in five of the cases. Although there was limited ability for follow-up, no known deaths occurred.

CONCLUSIONS

A high proportion of calls to the ID ADVISOR line are relevant to the overlapping content areas of infection prevention, force protection, and outbreak response. Most patients requiring urgent ID consultation were managed successfully without evacuation. The current military-unique ID fellowship curriculum is consistent with the encountered diagnoses per the ID ADVISOR line, and high-yield individual topics have been identified.

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.

Feasibility and Acceptability of a Model Disaster Teleconsultation System for Regional Disaster Health Response

Introduction: The federally funded Region 1 Regional Disaster Health Response System (RDHRS) and the American Burn Association partnered to develop a model regional disaster teleconsultation system within a Medical Emergency Operations Center (MEOC) to support triage and specialty consultation during a no-notice mass casualty incident. Our objective was to test the acceptability and feasibility of a prototype model system in simulated disasters as proof of concept. Methods: We conducted a mixed-methods simulation study using the Technology Acceptance Model framework. Participating physicians completed the Telehealth Usability Questionnaire (TUQ) and semistructured interviews after simulations. Results: TUQ item scores rating the model system were highest for usefulness and satisfaction, and lowest for interaction quality and reliability. Conclusions: We found high model acceptance, but desire for a simpler, more reliable technology interface with better audiovisual quality for low-frequency, high-stakes use. Future work will emphasize technology interface quality and reliability, automate coordinator roles, and field test the model system.

DOES THE APPLICATION OF CONVERSION FRACTURE-TREATMENT METHOD AND THE TECHNOLOGY OF TELEMEDICAL MOVEMENT MONITORING AFFECT THE LONG-TERM RESULTS OF THE TREATMENT OF VICTIMS WITH MULTIPLE GUNSHOT LONG BONES FRACTURES?

OBJECTIVE

The aim: To improve the results of treatment of patients with multiple gunshot fractures of long bones by developing the technology of fixation method conversion with combined autoplasty and postoperative telemedical control (loading +ROM (range of motion).

PATIENTS AND METHODS

Materials and methods: Two comparison groups were formed: the main (84 patients) and the control (62 patients). For the patients of this group all elements of the restorative treatment system were used (DCO, extrafocal osteosynthesis (including hinged), ultrasonic cavitation, NPWT, biochemical indicators of blood, conversion technology with usage of regenerative technologies, rehabilitation program) and telemedical control with applications (ROM+weight bearing). The control group (62 patients) - patients who received almost the same treatment, but only autoplasty with cancellous bone was included for bone plastics an telemedical counseling were not used.

RESULTS

Results: 1 year after the final method of fixation, it was established that the relative indicators were also lower in the patients of the main group, and a statistically significant difference was found in the indicator of the frequency of contracture formation, which may indicate the timely establishment of low dynamics in increasing the amplitude of movements and appropriate response (redress, arthrolysis, tenolysis).

CONCLUSION

Conclusions: Implementation of telemedicine and combined plastic surgery of bone defects in the restorative treatment system reduce the frequency of major complications that affect the objective result, affect better physical and mental health indicators during the observation period of 12 months.

Updated Review of the Pacific Asynchronous Telehealth System's Impact on Military Pediatric Teleconsultations

Introduction: The Pacific Asynchronous TeleHealth (PATH) system is an asynchronous provider-to-provider teleconsultation platform utilized by military medical facilities throughout the Western Pacific Region. This study focused on PATH utilization for pediatric cases and its impact on patient transfers and cost avoidance. Methods: This retrospective analysis reviewed PATH cases from March 2017 to February 2020 for patients aged 0-17 years. We reviewed the referring users' responses to survey questions related to the impact of PATH consultation on patient travel for in-person subspecialty care and the need for local referral. Data for cost avoidance were estimated using per diem rates and airline flight costs for Fiscal Year 2020. Results: A total of 2,448 pediatric consultations were submitted from 29 military medical facilities. Pediatric Pulmonology (n = 557, 24.5%), Pediatric Cardiology (n = 446, 19.6%), and Pediatric Neurology (n = 236, 10.37%) had the highest percentage of pediatric teleconsults. Approximately 42% of referring users completed the survey questions. Among survey respondents, 710 (69.4%) indicated that unnecessary patient transfers were prevented, equating to a cost savings of ∼$3.3 million. Conclusions: We observed robust utilization of the PATH system by pediatric providers in the Military Health System that ultimately resulted in substantial cost avoidance. This asynchronous telemedicine platform is a vital asset in locations with limited access or travel restriction to medical specialists, such as during pandemics.

Patient Satisfaction with Telephone Versus Video-Televisits: A Cross-Sectional Survey of an Urban, Multiethnic Population

OBJECTIVE

To examine differences between telephone and video-televisits and identify whether visit modality is associated with satisfaction in an urban, academic general urology practice.

METHODS

A cross sectional analysis of patients who completed a televisit at our urology practice (summer 2020) was performed. A Likert-based satisfaction telephone survey was offered to patients within 7 days of their televisit. Patient demographics, televisit modality (telephone vs video), and outcomes of the visit (eg follow-up visit scheduled, orders placed) were retrospectively abstracted from each chart and compared between the telephone and video cohorts. Multivariate regression analysis was used to evaluate variables associated with satisfaction while controlling for potential confounders.

RESULTS

A total of 269 patients were analyzed. 73% (196/269) completed a telephone televisit. Compared to the video cohort, the telephone cohort was slightly older (mean 58.8 years vs. 54.2 years, P = .03). There were no significant differences in the frequency of orders placed for medication changes, labs, imaging, or for in-person follow-up visits within 30 days between cohorts. Survey results showed overall 84.7% patients were satisfied, and there was no significant difference between the telephone and video cohorts. Visit type was not associated with satisfaction on multivariable analyses, while use of an interpreter [OR:8.13 (1.00-65.94); P = .05], labs ordered [OR:2.74 (1.12-6.70); P = .03] and female patient gender [OR:2.28 (1.03-5.03); P = .04] were significantly associated with satisfaction.

CONCLUSION

Overall, most patients were satisfied with their televisit. Additionally, telephone- and video-televisits were similar regarding patient opinions, patient characteristics, and visit outcome. Efforts to increase access and coverage of telehealth, particularly telephone-televisits, should continue past the COVID-19 pandemic.

The Trifecta of Tele-Critical Care: Intrahospital, Operational, and Mass Casualty Applications

INTRODUCTION

Tele-critical care (TCC) has improved outcomes in civilian hospitals and military treatment facilities (MTFs). Tele-critical care has the potential to concurrently support MTFs and operational environments and could increase capacity and capability during mass casualty events. TCC services distributed across multiple hub sites may flexibly adapt to rapid changes in patient volume and complexity to fully optimize resources. Given the highly variable census in MTF intensive care units (ICU), the proposed TCC solution offers system resiliency and redundancy for garrison, operational, and mass casualty needs, while also maximizing return on investment for the Defense Health Agency.

MATERIALS AND METHODS

The investigators piloted simultaneous TCC support to the MTF during three field exercises: (1) TCC concurrently monitored the ICU during a remote mass casualty exercise: the TCC physician monitored a high-risk ICU patient while the nurse monitored 24 simulated field casualties; (2) TCC concurrently monitored the garrison ICU and a remote military medical field exercise: the physician provided tele-mentoring during prolonged field care for a simulated casualty, and the nurse provided hospital ICU TCC; (3) the TCC nurse simultaneously monitored the ICU while providing reach-back support to field hospital nurses training in a simulation scenario.

RESULTS

TCC proved feasible during multiple exercises with concurrent tele-mentoring to different care environments including physician and nurse alternating operational and hospital support roles, and an ICU nurse managing both simultaneously. ICU staff noted enhanced quality and safety of bedside care. Field exercise participants indicated TCC expanded multipatient monitoring during mass casualties and enhanced novice caregiver procedural capability and scope of patient complexity.

CONCLUSIONS

Tele-critical care can extend critical care services to anywhere at any time in support of garrison medicine, operational medicine, and mass casualty settings. An interoperable, flexibly staffed, and rapidly expandable TCC network must be further developed given the potential for large casualty volumes to overwhelm a single TCC provider with multiple duties. Lessons learned from development of this capability should have applicability for managing military and civilian mass casualty events.

Implementation of Tele-Critical Care at General Leonard Wood Army Community Hospital

INTRODUCTION

Tele-Intensive Care Unit (tele-ICU) is care provided to critically ill patients by remote clinicians using audio, and video communications and network resources to access real-time patient information from physiologic monitors and the electronic medical record. Tele-ICU has been demonstrated in civilian healthcare to reduce mortality, improve care quality and safety, decrease intensive care unit (ICU) length of stay (LOS) and ventilator days, and save money. General Leonard Wood Army Community Hospital (GLWACH) is a small medical treatment facility with limited resources with respect to subspecialists and ancillary services.

MATERIALS AND METHODS

In 2012, GLWACH identified the lack of board-certified critical care physicians and limited baseline critical care capabilities as gaps that reduced surgical opportunities, challenged critical skill sustainment, exposed potential patient safety issues, and resulted in costly patient transfers to network hospitals. To address these gaps, GLWACH partnered with the Baptist Health Tele-ICU Service, located in Little Rock, AR, to provide Tele-ICU services to its four-bed intensive care unit. Video Teleconsultation (VTC) equipment was installed in the ICU as was a vendor specific solution for accessing real-time patient vital signs and an "emergency" button. The emergency button functioned by turning on the VTC equipment and calling the Tele-ICU center in Little Rock immediately when pushed. To assess impact, hospital and ICU volume, acuity, case mix index, purchased care costs were monitored before and after implementation of the system. Additionally, a Safety Attitudes Questionnaire (SAQ) was administered before and after implementation.

RESULTS

The implementation of the tele-ICU program at GLWACH increased hospital and ICU patient volume, surgical patient volume, and patient complexity. Purchased care costs declined by 30% in the year following implementation and return on investment was $233,311 (19%). All measurements of the SAQ improved following implementation.

CONCLUSIONS

These findings support the implementation of tele-ICU in the MHS as a cost-effective method to sustain readiness amongst critical care clinicians and improve safety culture in MHS hospitals.

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

National Health Service interventions in England to improve care to Armed Forces veterans

Armed Forces veterans (AFVs) are first and foremost citizens of the UK and are therefore—like all UK residents—entitled to universal healthcare, free at the point of need. This means that AFVs have nearly all their healthcare needs met by the NHS, which provides access to a full range of generic services. However, since 2013 there has been an Armed Forces team that can also support veterans. This review is an assessment of the work of this group over the last eight years. The health needs of AFVs have been investigated and are not significantly different from those of their demographically matched peers. However, due to their demographics, selection at recruitment and their roles, AFVs compared with the general population are more likely to be male, white and old and have fewer pre-existing or hereditary conditions. However, they do suffer from higher rates of musculoskeletal injury, different patterns of mental health illness and have historically been higher users—and abusers—of alcohol and tobacco. In addition to supporting mainstream services used by AFVs, the NHS in England commissions a bespoke range-specific ‘Priority’ NHS services such as those for mental health or for rehabilitation of veterans using prostheses. New interventions are continuing to be developed to improve AFVs’ healthcare and are aligned to the NHS Long Term Plan and the restoration and recovery plans after the COVID-19 pandemic.

The Development and Implementation of Specimens for Accident Forensic Toxicology Investigation Kit for Special Operations Forces

Introduction

After a vehicle rollover led to the death of a military member in Central Africa in 2018, it became apparent there was a significant gap in the capability to collect toxicology samples of Service Members involved in accidents and mishaps at remote Special Operations Forces locations in Africa. Multiple misconceptions surrounding sample collection, procedures for laboratory evaluation, and methods for shipment signaled the importance of establishing a procedure and a plan to provide the necessary medical inventory to properly collect and ship samples.

Materials and Methods

The Special Operations Command Africa (SOCAFRICA) Surgeon’s Office gathered the appropriate supplies for collection of forensic toxicology samples, and simultaneously developed a step-by-step checklist to safely and correctly perform urine and blood collection. The procedures were further improved after the completion of cognitive interviews with a Navy corpsman and Army Civil Affairs medic. Multiple shipping iterations occurred to ensure safe movement and arrival of samples at Armed Forces Medical Examiner System Dover AFB. Two Separate Specimens for Accident Forensic Toxicology Investigation Kits were generated to accommodate personnel typically associated with accidents involving vehicles and aircraft.

Results

SOCAFRICA’s toxicology kit supports legal and medical chain of custody requirements for investigations, and provides deployed forces in Africa with a mechanism to collect and ship samples from Africa to Dover AFB. The kits are provided to ensure these samples are successfully analyzed, thereby removing any ambiguity surrounding an accident or mishap.

Conclusion

SOCAFRICA established a prepared kit with all of the materials for sample collection, accompanied by step-by-step descriptions of the procedure, and clear guidance on the proper completion of the requisite paperwork that meets medico-legal requirements.

Blood Product Administration During the Role 1 Phase of Care: The Prehospital Trauma Registry Experience

BACKGROUND

The majority of combat deaths occur in the prehospital setting. Efforts to increase survival including blood transfusions are made in the prehospital setting. The blood products available in the Role 1 setting include whole blood (WB), red blood cells (RBCs), fresh frozen plasma (FFP), and lyophilized (freeze-dried) plasma (FDP).

METHODS

This is a secondary analysis of a previously published dataset within the Prehospital Trauma Registry (PHTR) from 2003 through May 2019. Deterministic linking was used when possible with the DoD Trauma Registry for outcome data. Descriptive statistics were used to analyze the data.

RESULTS

We identified 1,357 patient encounters in the PHTR. Within that group, 28 patients received a prehospital blood product, with 41 total administrations: WB (18), RBCs (12), FFP (6), FDP (3), and blood not otherwise specified (2). Outcome data were available for 17 of the 28 patients. The median injury severity score was 20, with the thorax being the most frequent seriously injured body region. Most (94%) patients survived to discharge. The median ICU days was 11 (Interquartile Range [IQR] 3-19), and the median hospital days was 19 (IQR 8-29). The average volume (units) of RBCs was 6.0 (95% CI 1.9-10.1), WB 2.8 (95% CI 0.0-5.6), platelets 0.7 (95% CI 0.0-1.4), and FFP 5.0 (95% CI 1.2-8.8).

CONCLUSIONS

The use of prehospital blood products is uncommon in U.S. combat settings. Patients who received blood products sustained severe injuries but had a high survival rate. Given the infrequent but critical use and potentially increased need for adequate prolonged casualty care in future near-peer conflicts, optimizing logistical chain circulation is required.

Military Telehealth: A Model For Delivering Expertise To The Point Of Need In Austere And Operational Environments

Austere clinical environments are those in which limited resources hamper the achievement of optimal patient outcomes. Operational environments are those in which caregivers and resources are at risk for harm. Military and civilian caregivers experience these environments in the context of war, natural disasters, humanitarian assistance missions, and mass casualty events. The military has a particular interest in enhancing local caregiver capabilities within austere and operational environments to improve casualty outcomes when evacuation is delayed or impossible, reduce the cost and the risk of unnecessary evacuations, enhance the medical response during aid missions, and increase combat effectiveness by keeping service members in the fight as long as possible. This article describes military telehealth as it relates to care in austere and operational environments, and it suggests implications for policy, particularly with respect to the current emphasis on telehealth solutions that might not be feasible in those settings.

Reduction in Medical Evacuations from Iraq and Syria Following Introduction of an Asynchronous Telehealth System

Introduction

While deployed, military medical personnel manage routine medical issues that fall under the category of Disease Non-Battle Injury (DNBI). The 86th Combat Support Hospital (CSH) partnered with Combined Joint Task Force-Operation Inherent Resolve (CJTF-OIR) Surgeon Cell, and Special Operations Joint Task Force-Operation Inherent Resolve (SOJTF-OIR) Surgeon Cell, to introduce the Health Experts onLine Portal (HELP) telemedicine system to medical personnel in Iraq and Syria. HELP is an asynchronous (store and forward) online system that provides secure provider-to-provider teleconsultation services for routine patient care and medical evacuation (MEDEVAC) coordination. The goal was to reduce the need for MEDEVAC by providing expert consultation to medical providers in farther-forward deployed units.

Material and Methods

In June 2017, the 86th CSH launched HELP telemedicine services for Kuwait. Following the successful implementation of the telemedicine system in Kuwait, the 86th CSH leadership partnered with CJTF-OIR and SOJTF-OIR medical leadership in launching the system within Iraq and Syria as well as making the system available to all deployed locations in Central Command (CENTCOM). This was a prospective cohort study designed to determine if having convenient and secure access to remote subspecialty consultation would be associated with a reduction in routine MEDEVACs from far forward in the battle space. In August 2017, new-user training was completed and the program launched in Iraq and Syria. This study analyzes the baseline MEDEVAC rate in 3 months before the implementation of HELP telemedicine compared to 3 months following the implementation.

Results

Iraq and Syria cases in the HELP telemedicine system accounted for 17.2% (76) of total CENTCOM telemedicine case volume over the 7-month study period. Comparing the 3-month period before and after implementation of HELP, use of asynchronous telemedicine in Iraq and Syria was associated with a reduction in total MEDEVACs from 157 to 68 (56.7% reduction, p &lt; 0.001). DNBI represented the majority of the change, (65.0% reduction, p &lt; 0.001). MEDEVAC for battle-related injuries decreased slightly from 13 to 6 per 3-month period (p = 0.03).

Conclusions

This is the first prospective study to demonstrate an association between the initiation of asynchronous telemedicine capabilities in a combat zone and decreased MEDEVACs. Annualized numbers would predict a reduction of 328 MEDEVACs/year for each 10,000 personnel by utilizing asynchronous telemedicine. This represents a significant potential cost savings of $1.2 million/year through avoidance of routine medical movement of personnel and supports unit readiness by retaining service members in areas of combat operations.

Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee

OBJECTIVES

In 2014, the Tele-ICU Committee of the Society of Critical Care Medicine published an article regarding the state of ICU telemedicine, one better defined today as tele-critical care. Given the rapid evolution in the field, the authors now provide an updated review.

DATA SOURCES AND STUDY SELECTION

We searched PubMed and OVID for peer-reviewed literature published between 2010 and 2018 related to significant developments in tele-critical care, including its prevalence, function, activity, and technologies. Search terms included electronic ICU, tele-ICU, critical care telemedicine, and ICU telemedicine with appropriate descriptors relevant to each sub-section. Additionally, information from surveys done by the Society of Critical Care Medicine was included given the relevance to the discussion and was referenced accordingly.

DATA EXTRACTION AND DATA SYNTHESIS

Tele-critical care continues to evolve in multiple domains, including organizational structure, technologies, expanded-use case scenarios, and novel applications. Insights have been gained in economic impact and human and organizational factors affecting tele-critical care delivery. Legislation and credentialing continue to significantly influence the pace of tele-critical care growth and adoption.

CONCLUSIONS

Tele-critical care is an established mechanism to leverage critical care expertise to ICUs and beyond, but systematic research comparing different models, approaches, and technologies is still needed.

Military Teleconsultation Services Facilitate Prompt Recognition and Treatment of a Case of Syphilitic Uveitis Aboard a United States Navy Aircraft Carrier at Sea During Combat Operations Without Evacuation Capability

Background: In the United States Armed Forces, telemedicine can bring specialist care into the field, augmenting the capabilities of health care providers in remote, austere environments to nearly the point of injury or illness. The early intervention enabled by telemedical consultation can not only guide crucial temporizing measures to safeguard life, limb, and eyesight, but can also facilitate care in resource limited environments, potentially avoiding need for patient evacuation. In circumstances when a higher level of care is needed, but unavailable or operationally not possible, telemedicine can guide management in the field until transport can be achieved. Methods: In the present case, a young male patient presented to medical company aboard a U.S. Navy aircraft carrier while deployed at sea for evaluation of an acute red eye. Despite initial therapeutic measures, his vision subsequently deteriorated. Uveitis was suspected, but transport off the ship to an eye care specialist was not possible during combat operations. Results: Telemedical consultation with shore-based ophthalmologists guided initial diagnostic and therapeutic efforts, resulting in the presumed diagnosis of syphilitic uveitis. With remote support of ophthalmology and infectious disease specialist care, the patient was treated at sea for this vision-threatening condition. As operational conditions allowed, the patient was later evacuated to definitive care. Conclusions: At follow up after treatment, the patient had an excellent visual outcome, and was promptly returned to duty.