Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals

Telemedicine in Acute Trauma Care: A Review of Quantitative Evaluations on the Impact of Remote Consultation

BACKGROUND

There is extensive literature describing the application of telemedicine techniques to trauma care. However, there is a paucity of articles showing quantitative assessment of its safety and efficacy. This structured review examines articles with quantitative assessment of telemedicine's impact in acute trauma care.

METHODS

Medline and CINAHL databases were searched for peer-reviewed articles that quantitatively assess the impact of telemedicine on diagnostic accuracy, clinical decision-making, emergency department length of stay, transfer rates, and mortality in initial trauma management.

RESULTS

Only 9 of the 408 screened articles met the criteria for quantitative assessment. Telemedicine appears to be preferentially used for more severely injured patients. Limited quality evidence supports procedural interventions at remote sites. Telemedicine may help abbreviate pre-transfer length of stay. However, its impact on diagnosis and mortality remains unclear.

CONCLUSIONS

Telemedicine's potential to enhance the quality and efficiency of trauma care, especially for resource-scarce areas, warrants continued quantitative research.

Effect of an image-sharing network on CT utilization for transferred trauma patients: a 5-year experience at a level I trauma center

PURPOSE

The aim of this study was to evaluate the influence of an image-sharing network established between referring hospitals and a level I trauma center on CT utilization at the trauma center.

METHODS

This retrospective study was approved by the local institutional review board. The requirement for informed consent was waived. Harborview Medical Center's trauma registry was linked to billing department data, and detailed information on all resources utilized during each patient's hospitalization was obtained. Negative binomial regression was used to evaluate body region-specific CT utilization between direct-admit and transfer patients after adjustment for potential confounding variables. Special attention was paid to 2005 as the year internet-based image sharing between Harborview Medical Center and referring hospitals was established.

RESULTS

A total of 81,159 trauma patients were admitted to Harborview Medical Center (44% transfers) during the study period. The utilization of head CT slightly increased from 1996 to 2005, with no significant difference between direct-admit and transfer patients. Between 2005 and 2010, utilization remained relatively unchanged; however, significantly higher utilization rates were observed for direct-admit patients. A relatively similar pattern was observed for pelvic CT; however, between 2005 and 2010, CT use was greater for direct-admit compared with transfer patients. Abdominal and thoracic CT was relatively unchanged between 2005 and 2010. However, both studies had significantly higher utilization rates for direct-admit patients.

CONCLUSIONS

The utilization rates of CT of different body regions have been higher for direct-admit trauma patients compared with transfer patients since 2005; however, decreasing utilization trends have been observed in recent years.

Transfer patient imaging: current status, review of the literature, and the Harborview experience

Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described.

[Digital X-ray: interhospital data transfer by CD-ROM. Prospective data evaluation during the import process]

BACKGROUND

Increasing numbers of radiological imaging diagnostics are archived in digital form. In addition to the results of diagnostics performed in hospital a growing number of patients present with digital results of outpatient radiological investigations. These digitized images represent a challenge for the internal hospital work flow. The aim of the study was to determine the expenditure for the hospital when dealing with digital outpatient diagnostic results.

METHOD

Several parameters were observed and analyzed within the import process of nearly 400 CD-ROMs over a time period of 5 months. Only a negligible number of data on CD-ROMs could not be transferred into the hospital archive (1.5%). The duration of the process depended on the amount of data and the time period.

RESULTS

During regular hours the import process took on average 13 min per CD and 19 min per patient while the time increased significantly during on-call duties. This study demonstrates the significance of the import of digital outpatient radiological diagnostic results into the hospital archive which can in particular influence patient treatment.

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient

BACKGROUND

Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations.

METHODS

A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview.

RESULTS

In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language.

CONCLUSIONS

The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

Quand faut-il décider d'un transfert en milieu neurochirurgical spécialisé?

The annual incidence of severe head injury lies between 9 and 25/100000 inhabitants, depending on the criteria used for its definition. In most countries, the shortage in neurosurgical ICU beds makes it impossible to take in charge all patients with a severe brain injury. But the beneficial effect of a specialized neurosurgical ICU on outcome after brain injury has been demonstrated in several retrospective studies. Ideally, the best strategy is to admit the patients with a severe head injury directly in a neurosurgical centre. When this is not possible, the appropriate decision of a secondary transfer relies on the quality of the relationships between physicians in the community and the neurosurgical hospitals. Teleradiology is the best method to avoid unnecessary transportation or deleterious delays before transfer. In an era of decreasing medical budgets, technical improvements to enhance medical cooperation should be encouraged.

Transfer of Pediatric Trauma Patients to a Tertiary Pediatric Trauma Centre: Appropriateness and Timeliness

OBJECTIVE

To study the appropriateness of, and time taken, to transfer pediatric trauma patients in New South Wales to The Children's Hospital at Westmead (CHW), a pediatric trauma center.

METHODS

All trauma patients transferred to CHW from June 2003 to July 2004 were included in the study. Indications and time periods relevant to the transfer of the patient from the referring institute were retrieved and analyzed. Pediatric and adult retrieval services were compared.

RESULTS

Three hundred ninety-eight patients were transferred to CHW, of whom 332 were from the metropolitan region. Falls and burns were the commonest mechanism of injury. Burn was the commonest indication for transfer (107 of 398). Mean Injury Severity Score was eight. Nearly half the patients had minor injuries (Injury Severity Score<9). Patients spent an average of 5 hours at the referring hospital. Pediatric retrieval ambulances had significantly longer mean transfer times than did nonpediatric ambulance services with a total time spent of about 2.64 hours versus 1.30 hours, respectively. For aeromedical transfers, on the other hand, the difference between pediatric retrieval services and nonpediatric air ambulances was not significant.

CONCLUSIONS

The majority of the patients transferred had minor injuries. Pediatric trauma patients spend considerable time in their referring hospitals. Pediatric retrieval services appear to take significantly longer to transfer patients than nonpediatric ambulance transfers even after allowing for patient age and injury severity. Although this did not result in mortality or morbidity, there appears to be considerable scope for a reduction in transfer times through better coordination of these services.

Clinical outcomes associated with telemedicine/telehealth

This paper is a comprehensive review and synthesis of the literature concerning clinical outcomes associated with various telemedicine applications. It starts out with a brief description of the findings reported by similar literature reviews already published. Subsequently, it proposes a conceptual model for assessing clinical outcomes based on Donabedian's formulation of the Medical Care Process. Accordingly, research findings are reported in terms of the relevant components of the medical care process, namely, diagnosis, clinical management, and clinical outcomes. Specific findings are organized according to the designated clinical and diagnostic application. This is followed by a general report of studies dealing with patient satisfaction.

Teleconsultation with the mobile camera-phone in digital soft-tissue injury: a feasibility study

The purpose of this study was to examine the feasibility of teleconsultation using a mobile camera-phone to evaluate the severity of digital soft-tissue injury and to triage the injury with regard to management recommendations. With a built-in 110,000-pixel digital camera, pictures of the injured digit(s) or radiograph were taken by surgical residents in the emergency room and transmitted to another camera-phone to be viewed by the remote consultant surgeon. A brief medical and trauma history of each patient was relayed also by mobile phone. The consultant surgeon then reviewed all of these patients in the emergency room shortly after the initial telemedicine referral. Separate triaging for each digital injury into three groups was recorded during remote teleconsultation and according to actual treatment by the attending surgeon as follows: group I, the injury could be managed with conservative treatment, such as secondary intention wound healing, or primary closure with or without bone shortening; group II, skin grafting or local flap coverage was required for management of the injury; and group III, microsurgery such as replantation or free flap coverage was necessary to deal with the injury. Later, triaging was also performed individually by three junior plastic residents according to image review and patient referral information. Teleconsultation through a mobile camera-phone was performed for 45 patients with injuries of 81 digits from January to May of 2003. Of these 81 digital injuries, there were 12 cases (15 percent) where disagreement of triaging occurred between the teleconsultation and the actual treatment by the attending surgeon. In image reviewing, there was 79 percent sensitivity and 71 percent specificity in remote diagnosis of the skin defect and 76 percent sensitivity and 75 percent specificity in remote identification of the bone exposure regarding the concordance of opinions of all three surgeons; there was significant discordance in triaging in 20 cases (25 percent), and the difference in triaging was partly attributed to the inability to show instances of tiny exposed digital bone or tendon in some cases under the low-resolution digital image and the situation of a bloody oozing wound. In some cases, the difficulty in evaluating the probability of primary closure of severely avulsed skin edges or the probability of executing replantation for finger amputation also contributed to different triaging outcomes. Two neglected diagnoses of transected digital nerves were found and influenced triaging, highlighting the importance of on-site physical examination during teleconsultation. The telemedicine system using a mobile camera-phone based on the global system for mobile communication is feasible and valuable for early diagnosis and triaging of digital soft-tissue injury in emergency cases, with on-line verbal communication and review of the transmitted captured image. This system has the advantages of ease of use, low cost, high portability, and mobility. With advances in hardware for digital imaging and transmission technology and the development of the third-generation advanced mobile phone system in the foreseeable future, this system has potential for future applications in telemedicine and telecare.

Teleconsultation by Using the Mobile Camera Phone for Remote Management of the Extremity Wound

To assess the feasibility of remote management of extremity wound by using a mobile camera phone to transfer clinical images and online communication, teleconsultations were carried out on 60 patients between January and August 2003 for 82 extremity wounds presented to the emergency room between residents and consultant plastic surgeons. A questionnaire about wound descriptors (gangrene, necrosis, erythema, and cellulitis/infection), as well as clinical opinions regarding treatment with antibiotics or debridement, was filled out. In this study, 3 surgeons were able to make 80%, 76%, 66%, and 74% agreement, respectively, in the remote diagnosis regarding presence of gangrene, necrosis, erythema, and cellulitis/infection. Recognition of gangrene had the highest agreement percent (80%), sensitivity (85%), and specificity (93%). There were 68% to 90% of image sets that could be made with equivalent diagnoses of wound descriptors and 83% of wounds managed as per the remote treatment recommendation regarding whether to use antibiotics or to perform debridement. The preliminary results showed that the camera phone is valuable and bears potential for remote management of the extremity wound.

Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST)

BACKGROUND

Thoracic ultrasound (EFAST) has shown promise in inferring the presence of post-traumatic pneumothoraces (PTXs) and may have a particular value in identifying occult pneumothoraces (OPTXs) missed by the AP supine chest radiograph (CXR). However, the diagnostic utility of hand-held US has not been previously evaluated in this role.

METHODS

Thoracic US examinations were performed during the initial resuscitation of injured patients at a provincial trauma referral center. A high frequency linear transducer and a 2.4 kg US attached to a video-recorder were used. Real-time EFAST examinations for PTXs were blindly compared with the subsequent results of CXRs, a composite standard (CXR, chest and abdominal CT scans, clinical course, and invasive interventions), and a CT gold standard (CT only). Charts were reviewed for in-hospital outcomes and follow-up.

RESULTS

There were 225 eligible patients (207 blunt, 18 penetrating); 17 were excluded from the US examination because of battery failure or a lost probe. Sixty-five (65) PTXs were detected in 52 patients (22% of patients), 41 (63%) being occult to CXR in 33 patients (14.2% whole population, 24.6% of those with a CT). The US and CXR agreed in 186 (89.4%) of patients, EFAST was better in 16 (7.7%), and CXR better in 6 (2.9%). Compared with the composite standard, the sensitivity of EFAST was 58.9% with a likelihood ratio of a positive test (LR+) of 69.7 and a specificity of 99.1%. Comparing EFAST directly to CXR, by looking at each of 266 lung fields with the benefit of the CT gold standard, the EFAST showed higher sensitivity over CXR (48.8% versus 20.9%). Both exams had a very high specificity (99.6% and 98.7%), and very predictive LR+ (46.7 and 36.3).

CONCLUSION

EFAST has comparable specificity to CXR but is more sensitive for the detection of OPTXs after trauma. Positive EFAST findings should be addressed either clinically or with CT depending on hemodynamic stability. CT should be used if detection of all PTXs is desired.

Outcomes and Methods in Telemedicine Evaluation

One hundred and four articles, published from 1966 to 2000, were reviewed to investigate telemedicine evaluation studies in terms of methods and outcomes. A total of 112 evaluations were reported in these 104 articles. Two types of evaluations were evaluated: clinical and nonclinical. Within the clinical evaluations, three were on clinical effectiveness, 26 on patient satisfaction, 49 on diagnostic accuracy, and nine on cost. In the non-clinical evaluations, 15 articles discussed technical issues relating to digital images, such as bandwidth, resolution, and color, and 10 articles assessed management issues concerning efficiency of care, such as avoiding unnecessary patient transfer, or saving time. Of the 112 evaluations, 72 were descriptive in nature. The main methods used in the remaining 40 articles used quantitative methods. Nineteen articles employed statistical techniques, such as receiver operating characteristics curve (three evaluations) and kappa values (seven evaluations). Only one article utilized a qualitative approach to describe a telemedicine system. Currently, there are a number of good reports on diagnostic accuracy, satisfaction, and technological evaluation. However, clinical effectiveness and cost-effectiveness are important parameters, and they have received limited attention. Since telemedicine evaluations tend to explore various outcomes, it may be appropriate to evaluate from a multidisciplinary perspective, and to utilize various methodologies.

Theory and applications of telemedicine

In this study, telemedicine and the use of advanced telemedicine technologies are explained. Telemedicine is the use of modern telecommunications and information technologies for the provision of clinical care to individuals at a distance, and transmission of information to provide that care. Telemedicine can be used for decision making, remote sensing, and collaborative arrangements for the real-time management of patients at a distance. The use of telecommunications and information technologies in providing health services is determined. Telemedicine is described as combination of topics from the fields of telecommunication, medicine, and informatics. The medical systems infrastructure consisting of the equipment and processes used to acquire and present clinical information and to store and retrieve data are explained in details. The challenges existing in telemedicine development in different countries are given. Technological, political, and professional barriers in applications of telemedicine are defined. An investigation of telemedicine applications in various fields is presented, and enormous impact of telemedicine systems on the future of medicine is determined.

Interhospital transport: transport of critically ill patients

Primary emergency medicine systems in developed countries are well organized. Besides this primary system a secondary interhospital transport system has been developed in the past decade. The need for this system is expected to increase in the future following dramatic changes in the organization of the medical health system. This article outlines the current status of these secondary interhospital transfer systems, their components, possibilities, advantages or disadvantages, and the actual literature. Surprisingly, the available scientific data on these cost-intensive and highly developed systems are quite insufficient.

The eICU: it's not just telemedicine

Intensive care units (ICUs) are major sites for medical errors and adverse events. Suboptimal outcomes reflect a widespread failure to implement care delivery systems that successfully address the complexity of modern ICUs. Whereas other industries have used information technologies to fundamentally improve operating efficiency and enhance safety, medicine has been slow to implement such strategies. Most ICUs do not even track performance; fewer still have the capability to examine clinical data and use this information to guide quality improvement initiatives. This article describes a technology-enabled care model (electronic ICU, or eICU) that represents a new paradigm for delivery of critical care services. A major component of the model is the use of telemedicine to leverage clinical expertise and facilitate a round-the-clock proactive care by intensivist-led teams of ICU caregivers. Novel data presentation formats, computerized decision support, and smart alarms are used to enhance efficiency, increase effectiveness, and standardize clinical and operating processes. In addition, the technology infrastructure facilitates performance improvement by providing an automated means to measure outcomes, track performance, and monitor resource utilization. The program is designed to support the multidisciplinary intensivist-led team model and incorporates comprehensive ICU re-engineering efforts to change practice behavior. Although this model can transform ICUs into centers of excellence, success will hinge on hospitals accepting the underlying value proposition and physicians being willing to change established practices.

Telemedicine: a solution to the followup of rural trauma patients?

BACKGROUND

Outpatient followup of rural trauma patients is problematic for physicians and patients. Our hypothesis was that telemedicine-based followup of trauma patients discharged to remote areas is feasible and is associated with high patient and physician satisfaction.

STUDY DESIGN

We chose 11 counties in Kentucky surrounding a remote telemedicine site as our region of interest. Any adult trauma patient who was discharged from our Level I trauma center to this geographic region was eligible to have routine followup appointment(s) at the TeleTrauma Clinic. Patients were examined and interviewed with the assistance of a nurse, an electronic stethoscope, and a close-up imaging instrument. Radiographs performed at the telemedicine site were viewed. Patients and physicians completed a survey after the appointment.

RESULTS

To date, we have conducted 22 telemedicine-based followup assessments of trauma patients. The average age and Injury Severity Score were 42 years and 18, respectively. Plain radiographs were reviewed in 13 cases. Our patient surveys indicated a high degree of satisfaction with the teleappointment. In 15 of 22 patients, no further clinical followup was arranged. The differences in travel distances and times for an appointment at the TeleTrauma Clinic versus an appointment at our Level I trauma center were significant. The average and median duration of the appointments was 14 minutes. All telemedicine encounters were done by two physicians, who recorded a high level of satisfaction.

CONCLUSIONS

Our early experience with the outpatient followup of remote trauma victims by telemedicine is encouraging. Patient surveys indicate a high degree of satisfaction. As a result of our favorable experience, telemedicine-based followup may be expanded to other regions of Kentucky.

Trauma systems

Trauma is one of the major causes of death and disability in modern society, particularly for the young. Organized trauma systems reduce mortality and morbidity from trauma. An effective trauma system addresses all aspects of trauma care, from prevention to rehabilitation. Well-developed trauma systems are currently available only to a minority of the world's population. Trauma systems in developed nations have much potential for improvement.

Telemedicine

Telemedicine began from the humble beginnings of the first telephone call from Alexander Graham Bell to his associate, Watson. These systems already have been used for educational programs, consultative care, image transfer, second opinions, and direct acute patient care. Most of the original programs failed because of several reasons, primarily because of lack of funding when a grant ended. The major lesson of these programs is that a solid business plan is needed initially for long-term survival. The reliability of telemedical examinations has been demonstrated superficially, but more conclusive work in this area is needed. Studies that evaluate clinical, financial, and satisfaction outcomes are required simultaneously. Further integration of medical informatics into telemedicine systems is needed before these systems can achieve more acceptance. Twenty years ago, few people predicted this technologic revolution. Innovations arise almost daily. The future seems promising for telemedical systems, but much work is required. Partnerships with industry must move beyond niche projects, and regulatory and medicolegal issues must be resolved. Anesthesiologists can expect their practice to be affected directly by technology, and should embrace it, evaluate it, and help lead its use in this millennium.

Remote access to critical care

As we all begin to focus more on errors in medicine, telemedicine applications will expand. Remote access to experts will be required. Although telemedicine has always existed as a component of medicine, it was usually designed for niche areas. Telemedicine consists of information sharing between at least two physically and geographically disparate sites for educational or health purposes. Although telemedicine in the intensive care unit may at first seem absurd to many clinicians, most care providers have, in fact, used some form of telemedicine to provide care for decades. All of us have managed patients by telephone communication with nurses, residents, or other physicians. Besides augmenting routine care in the intensive care unit, telemedicine is providing essential tools that improve the efficiency of health care communication and add safety for the health care provider by making health care available under less than ideal circumstances, such as a terrorist attack with biologic weapons. The future appears quite bright for telemedicine systems, but much work is still required. How payers, lawyers, and ethicists view telemedicine is not yet completely understood. As intensivists, we should expect our practice to be directly impacted by this maturing technology. We should wholeheartedly embrace it and help lead its use in this new millennium.

Supervising trauma life support by telemedicine

The resuscitation room in a community hospital was linked with a main hospital accident and emergency department using telemedicine equipment working at 384 kbit/s. Fifteen simulated casualties replicated the 'moulage' scenarios in the Advanced Trauma Life Support Course Manual of the American College of Surgeons. Each of the 15 scenarios was broken down into three main parts: the primary survey, resuscitation and the secondary survey. While a physician in the community hospital undertook each task, a senior doctor in the accident and emergency department recorded his degree of confidence in the supervision of the task on a five-point scale. There were features of the management which the supervisor found difficult, mainly related to the camera view and the use of a proxy examiner. However, supervising major trauma management by telemedicine was feasible. The average scores were mostly above 3 and often above 4 in the assessment of the primary survey and the resuscitation. The average scores were mostly above 3 for the secondary survey but were less often above 4 than for the primary survey and the resuscitation. Trials of remote trauma management with real patients appear to be justified.