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Patel P, Aucar J. Telemedicine in Acute Trauma Care: A Review of Quantitative Evaluations on the Impact of Remote Consultation. Am Surg 2024:31348241265146. [PMID: 39037713 DOI: 10.1177/00031348241265146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
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.
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Affiliation(s)
- Prem Patel
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John Aucar
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
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2
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Schoen JC, Klipfel JM, Torbenson VE, DeWitt JJ, Sadosty AT, Theiler RN. Leveraging In Situ Simulation for Implementation of Teleobstetric Consultation Services in Rural and Community Hospitals. Telemed J E Health 2024. [PMID: 38946617 DOI: 10.1089/tmj.2023.0649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Background: Our institution implemented acute-care obstetric (OB) telemedicine (TeleOB) to address rural disparities across our health system. We sought to determine whether in situ simulations with embedded TeleOB consultation increase participants' comfort managing OB emergencies and comfort with and likelihood of using TeleOB. Methods: Rural site care teams participated in multidisciplinary in situ OB emergency simulations. Physicians in OB and neonatology at the referral center assisted via telemedicine consultation. Participants were surveyed before and after the simulations and six months later regarding their experience during the simulations. Results: Participants reported increased comfort with TeleOB activation, indications, and workflow processes, as well as increased comfort managing OB emergencies. Participants also reported significantly increased likelihood of using TeleOB in the future. Conclusions: Consistent with previous work, in situ simulation with embedded telemedicine consultations is an effective approach to facilitate telemedicine implementation and promote use by rural clinicians.
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Affiliation(s)
- Jessica C Schoen
- Mayo Clinic Multidisciplinary Simulation Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic Health System Albert Lea and Austin, Austin, Minnesota, USA
| | - Janee M Klipfel
- Mayo Clinic Multidisciplinary Simulation Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Vanessa E Torbenson
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason J DeWitt
- Department of Obstetrics and Gynecology, Mayo Clinic Health System Southwest Minnesota, Mankato, Minnesota, USA
| | - Anne T Sadosty
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Regan N Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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Santomauro C, McLanders M, Rae A. Experiences of rural clinicians accessing specialist support via telehealth for trauma and emergency care in Queensland, Australia. Digit Health 2024; 10:20552076241251950. [PMID: 39070889 PMCID: PMC11282562 DOI: 10.1177/20552076241251950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 07/30/2024] Open
Abstract
Objective Trauma and emergency patients presenting to rural facilities require time-critical treatment and management that is sometimes beyond the scope of clinicians in the facility. In Queensland, Australia's second largest state, telehealth infrastructure facilitates 24/7 communication between rural clinicians and tertiary-based critical care specialists. We sought to understand the current state of Queensland's emergency telehealth system from the perspective of direct end-users to inform future improvement efforts and resource allocation. Methods Semi-structured interviews were conducted with 11 rural Queensland clinicians who use telehealth to access specialist support during critical presentations. Qualitative data were analysed in three inductive phases: immersion; a combination of process coding and in vivo coding; and focused coding. Results The findings highlight that emergency telehealth support provides benefits beyond better patient care, as it fosters collegiality and alleviates professional isolation. Three key themes were identified: (a) strategies for overcoming challenges in providing trauma and emergency care in rural Queensland; (b) factors that affect perceptions of telehealth effectiveness; and (c) how support for rural trauma and emergency care can be improved. To provide context for the themes, a summary of scene-setting data is also provided. Conclusions There are both advantages and disadvantages for rural clinicians accessing telehealth specialist support for critical care. Although telehealth is seen as a vital service that supports rural clinicians and benefits patient care, the findings suggest that tools, systems and processes surrounding rural trauma and emergency care could benefit from streamlining, integration, and the introduction of fit-for-purpose technologies. Addressing limitations of efficiencies would improve support for rural clinicians and likely improve patient outcomes for rural communities.
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Affiliation(s)
- Chiara Santomauro
- Safety Science Innovation Lab, Griffith University, Brisbane, QLD, Australia
- School of Psychology, The University of Queensland, Brisbane, QLD, Australia
| | - Mia McLanders
- Safety Science Innovation Lab, Griffith University, Brisbane, QLD, Australia
- School of Psychology, The University of Queensland, Brisbane, QLD, Australia
- Clinical Skills Development Service, Metro North Health, Brisbane, QLD, Australia
| | - Andrew Rae
- Safety Science Innovation Lab, Griffith University, Brisbane, QLD, Australia
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Choi W, Lim Y, Heo T, Lee S, Kim W, Kim SC, Kim Y, Kim J, Kim H, Kim H, Lee T, Kim C. 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. J Clin Med 2023; 12:6252. [PMID: 37834896 PMCID: PMC10573876 DOI: 10.3390/jcm12196252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
(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.
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Affiliation(s)
- WooSung Choi
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| | - YongSu Lim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
- Department of Emergency Medicine, Gachon University College of Medicine, Incheon 21565, Republic of Korea
| | - Tag Heo
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea; (T.H.); (S.L.)
| | - SungMin Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea; (T.H.); (S.L.)
| | - Won Kim
- Department of Emergency Medicine, Cheju Halla General Hospital, Jeju 63127, Republic of Korea;
| | - Sang-Chul Kim
- Department of Emergency Medicine, Chungbuk National University College of Medicine, Cheongju 28644, Republic of Korea;
| | - YeonWoo Kim
- Department of Emergency Medicine, Andong Medical Center, Andong 36743, Republic of Korea;
| | - JaeHyuk Kim
- Department of Emergency Medicine, Mokpo Hangook Hospital, Mokpo 58643, Republic of Korea;
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea;
| | - HyungIl Kim
- Department of Emergency Medicine, Dankook University College of Medicine, Cheonan 31116, Republic of Korea;
| | - TaeHun Lee
- Department of Emergency Medicine, Chuncheon Sacred Heart Hospital, Chuncheon 24253, Republic of Korea;
| | - Chol Kim
- Department of Emergency Medicine, Saint Carollo General Hospital, Suncheon 57931, Republic of Korea;
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5
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Hayden EM, Davis C, Clark S, Joshi AU, Krupinski EA, Naik N, Ward MJ, Zachrison KS, Olsen E, Chang BP, Burner E, Yadav K, Greenwald PW, Chandra S. Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine. Acad Emerg Med 2021; 28:1452-1474. [PMID: 34245649 PMCID: PMC11150898 DOI: 10.1111/acem.14330] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. METHODS Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." RESULTS Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). CONCLUSION The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.
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Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Aditi U Joshi
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Neel Naik
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Olsen
- Department of Emergency Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth Burner
- Department of Emergency Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Peter W Greenwald
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Shruti Chandra
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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Tsou C, Robinson S, Boyd J, Jamieson A, Blakeman R, Yeung J, McDonnell J, Waters S, Bosich K, Hendrie D. Effectiveness of Telehealth in Rural and Remote Emergency Departments: Systematic Review. J Med Internet Res 2021; 23:e30632. [PMID: 34842537 PMCID: PMC8665379 DOI: 10.2196/30632] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/24/2021] [Accepted: 09/12/2021] [Indexed: 01/18/2023] Open
Abstract
Background Emergency telehealth has been used to improve access of patients residing in rural and remote areas to specialist care in the hope of mitigating the significant health disparities that they experience. Patient disposition decisions in rural and remote emergency departments (EDs) can be complex and largely dependent on the expertise and experience available at local (receiving-end) hospitals. Although there has been some synthesis of evidence of the effectiveness of emergency telehealth in clinical practice in rural and remote EDs for nonacute presentations, there has been limited evaluation of the influence of contextual factors such as clinical area and acuity of presentation on these findings. Objective The aims of this systematic review are to examine the outcome measures used in studying the effectiveness of telehealth in rural and remote EDs and to analyze the clinical context in which these outcome measures were used and interpreted. Methods The search strategy used Medical Subject Headings and equivalent lists of subject descriptors to find articles covering 4 key domains: telehealth or telemedicine, EDs, effectiveness, and rural and remote. Studies were selected using the Population, Intervention, Comparator, Outcomes of Interest, and Study Design framework. This search strategy was applied to MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, and EconLit, as well as the Centre for Reviews and Dissemination databases (eg, National Health Service Economic Evaluation Database) for the search period from January 1, 1990, to May 23, 2020. Qualitative synthesis was performed on the outcome measures used in the included studies, in particular the clinical contexts within which they were interpreted. Results A total of 21 full-text articles were included for qualitative analysis. Telehealth use in rural and remote EDs demonstrated effectiveness in achieving improved or equivalent clinical effectiveness, appropriate care processes, and—depending on the context—improvement in speed of care, as well as favorable service use patterns. The definition of effectiveness varied across the clinical areas and contexts of the studies, and different measures have been used to affirm the safety and clinical effectiveness of telehealth in rural and remote EDs. The acuity of patient presentation emerged as a dominant consideration in the interpretation of interlinking time-sensitive clinical effectiveness and patient disposition measures such as transfer and discharge rates, local hospital admission, length of stay, and ED length of stay. These, together with clinical area and acuity of presentation, are the outcome determination criteria that emerged from this review. Conclusions Emergency telehealth studies typically use multiple outcome measures to determine the effectiveness of the services. The outcome determination criteria that emerged from this analysis are useful when defining the favorable direction for each outcome measure of interest. The findings of this review have implications for emergency telehealth service design and policies. Trial Registration PROSPERO CRD42019145903; https://tinyurl.com/ndmkr8ry
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Affiliation(s)
- Christina Tsou
- School of Population Health, Curtin Univeristy, Bentley, Australia.,Innovation & Development, WA Country Health Service, Perth, Australia
| | - Suzanne Robinson
- School of Population Health, Curtin Univeristy, Bentley, Australia
| | - James Boyd
- Digital Health, La Trobe University, Bundoora, Australia
| | - Andrew Jamieson
- Innovation & Development, WA Country Health Service, Perth, Australia
| | - Robert Blakeman
- Consumer and Community Health Research Network, Nedlands, Australia.,Consumer and Mental Health WA, Cloverdale, Australia
| | - Justin Yeung
- Command Centre, WA Country Health Service, Perth, Australia
| | | | - Stephanie Waters
- Innovation & Development, WA Country Health Service, Perth, Australia
| | - Kylie Bosich
- Command Centre, WA Country Health Service, Perth, Australia
| | - Delia Hendrie
- School of Population Health, Curtin Univeristy, Bentley, Australia
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Taylor MA, Lewis AE, Swendiman RA, Fenton SJ, Russell KW. Interest in Improving Access to Pediatric Trauma Care Through Telemedicine. J Med Syst 2021; 45:108. [PMID: 34755231 DOI: 10.1007/s10916-021-01789-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 11/01/2021] [Indexed: 11/25/2022]
Abstract
Despite improved outcomes at pediatric trauma centers (PTC), 90% of injured children are not treated at PTCs. Telemedicine may play a role in ensuring patients are transferred to the appropriate level of care. We aimed to determine the level of interest in trauma telemedicine with our PTC among referring facilities. A survey was conducted with the trauma program directors of 45 hospitals in Utah, which consisted of four multiple choice questions designed to determine interest in pediatric trauma telemedicine support, projected frequency of use, anticipated uses of telemedicine, and perceived barriers to implementation. Forty-one directors (91%) responded. 88% of directors were interested in developing a pediatric trauma telemedicine network. 20% estimated their center would use telemedicine more than once a week, 17% once a week, 24% once a month, and 37% a few times a year. The most frequently cited uses of a telemedicine program were triage/transfer decisions and provider support. Inadequate volume and insufficient funding were the most common perceived barriers. These data show there is a strong interest amongst hospitals in our state in pediatric trauma telemedicine. Inadequate volume to warrant a program and insufficient facility funding remain concerns for development of a program.
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Affiliation(s)
- Mark A Taylor
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA.
| | - Aislinn E Lewis
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | | | - Stephen J Fenton
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Katie W Russell
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
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8
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Omari AM, Antonacci CL, Zaifman J, Johal A, Conway J, Mahmood Y, Klein GR, Alberta FG, Koerner JD. Patient Satisfaction with Orthopedic Telemedicine Health Visits During the COVID-19 Pandemic. Telemed J E Health 2021; 28:806-814. [PMID: 34724833 DOI: 10.1089/tmj.2021.0170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background: Telemedicine usage in orthopedic surgery has seen a dramatic increase as a result of the severe acute respiratory syndrome coronavirus 2 pandemic. The purpose of this study was to examine patient perceptions with telemedicine at a large orthopedic practice. Materials and Methods: An anonymous online survey was distributed to all patients who received a telemedicine health visit at our institution for musculoskeletal complaints from March 17 to June 1, 2020. Responses were scored on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree, 1-5) and analyzed by average score and percent reaching top box. Results: A majority of patients (76.5%) were satisfied with their visit, and only 19.2% did not want telemedicine as a future option. Patients who presented for follow-up visits (4.11 vs. 3.94, p = 0.0053; 48% vs. 41%, p = 0.02) and utilized video (4.21 vs. 3.88, p < 0.001; 51% vs. 39%, p < 0.001) were more satisfied. Average satisfaction between older (>65 years) and younger patients was similar (4.06 vs. 4.06, p = 0.97), however, younger patients were more likely to reach top box (42% vs. 51%, p < 0.001). Confidence that the physician came to the correct diagnosis (r = 0.78, p < 0.001) and receiving the same information and care as an in-office visit (r = 0.60, p < 0.001) demonstrated the strongest correlation with satisfaction and desire for future telemedicine visits, respectively. Interestingly, 31.1% of patients would have sought treatment elsewhere had telemedicine not been an option. Conclusions: Overall, satisfaction rates are high for orthopedic patients undergoing telemedicine visits. Patients are more confident in telemedicine when presenting for a follow-up visit and with the use of video.
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Affiliation(s)
- Ali M Omari
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Christopher L Antonacci
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA.,Department of Orthopaedics, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jay Zaifman
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Anmol Johal
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Jolie Conway
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Yusuf Mahmood
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Gregg R Klein
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA.,Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.,Department of Orthopaedic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Frank G Alberta
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA.,Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.,Department of Orthopaedic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - John D Koerner
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA.,Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.,Department of Orthopaedic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
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9
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Wood T, Freeman S, Banner D, Martin-Khan M, Hanlon N, Flood F. Exploring user perspectives of factors associated with use of teletrauma in rural areas. Australas Emerg Care 2021; 25:106-114. [PMID: 33972192 DOI: 10.1016/j.auec.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite the existence of universal health care for Canadians, health inequalities persist and those residing in rural regions experience disparities when accessing appropriate services. To enhance access, a teletrauma program was implemented in a rural northern region in western Canada, connecting rural clinicians to urban emergency physicians and trauma specialists during emergency cases. OBJECTIVE To explore reasons why teletrauma is used in rural contexts from the perspectives of service users and stakeholders. METHODS 14 semi-structured interviews were conducted with stakeholders, clinicians (physicians, specialists), management, and researchers. Interpretive description methodology guided the study and analysis, and findings were organized thematically. RESULTS Teletrauma was used to connect clinicians, manage complex cases when weather or distance delayed transfer, and to enable appropriate and timely treatment locally. Teletrauma was more likely to be activated when clinicians were uncomfortable with clinical management, when relationships were established, and when technology was familiar and easy to use. CONCLUSIONS Teletrauma is more than just the technology that is deployed. The establishment of relationships between teletrauma users was vital to the success of teletrauma. To design effective, integrated, and sustainable services, rural clinicians must remain at the center of teletrauma models.
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Affiliation(s)
- Timothy Wood
- University of Northern British Columbia, School of Nursing, Canada
| | - Shannon Freeman
- University of Northern British Columbia, School of Nursing, Canada.
| | - Davina Banner
- University of Northern British Columbia, School of Nursing, Canada
| | | | - Neil Hanlon
- University of Northern British Columbia, School of Geography, Canada
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10
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Taylor MA, Knochel ML, Proctor SJ, Brockmeyer DL, Runyon LA, Fenton SJ, Russell KW. Pediatric trauma telemedicine in a rural state: Lessons learned from a 1-year experience. J Pediatr Surg 2021; 56:385-389. [PMID: 33228973 DOI: 10.1016/j.jpedsurg.2020.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous research from our center has shown that 27% of the pediatric trauma transfers from referring facilities are potentially preventable. Our hospital is the only level 1 pediatric trauma center (PTC) in our state, and we are developing a pediatric trauma telehealth network to help keep certain injured children closer to home. We instituted a pediatric trauma telehealth program with a partnering community-based hospital in our state and aim to report our experience over the first year. METHODS All pediatric trauma patients that presented to our partnering hospital from January 2019 to February 2020 were reviewed. Disposition was: a) telehealth consultation, b) admission to the children's unit without a telehealth consultation per our head trauma protocol, or c) transfer without telehealth consultation. Data on demographics, hospital course, and disposition were collected via chart review. RESULTS Eight patients underwent telehealth consults and another 8 patients were admitted to the partnering hospital's children's unit based on the head trauma protocol without a telehealth consult. Patient's ages ranged from 7 months to 15 years. Of the patients that underwent telehealth consult, 7 presented with a head injury and 1 presented with a rib fracture/small pneumothorax. The patient with a pneumothorax was observed for 6 h and discharged home after a repeat chest x-ray was stable. All 15 patients with head injuries were observed and discharged from either the emergency department or children's unit after passing concussion testing. No patients required transfer to our PTC after observation, and none were readmitted. Fifty-six patients were transferred without telehealth consultation, and 3 of these patients could potentially have avoided transfer with a telehealth consultation. CONCLUSIONS Telehealth in pediatric trauma can be a safe mechanism for preventing the transfer of patients that can be safely observed at a partnering hospital. From a facility that transfers an average of 30 trauma patients per year to our hospital, this program prevented 16 such transfers. Development of a head trauma protocol in collaboration with a pediatric neurosurgeon leads to an unexpected number of patients being admitted to the partnering hospital for observation without utilization of a telehealth consultation. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mark A Taylor
- University of Utah, Department of Surgery, Salt Lake City, UT.
| | - Miguel L Knochel
- University of Utah, Department of Pediatrics, Salt Lake City, UT
| | | | | | - Lisa A Runyon
- Primary Children's Hospital, Department of Pediatric Surgery, Salt Lake City, UT
| | | | - Katie W Russell
- University of Utah, Department of Surgery, Salt Lake City, UT
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11
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Lee C, Yugendra P, Wee CPJ, Pek JH. Necessity of trauma referrals to the emergency department. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820932611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patients with traumatic injuries presenting to the emergency department (ED) may be referred to another hospital for further management. Unnecessary referrals can inflate health-care costs and workload, as well as reduce provider and patient satisfaction. Objectives: In this study, we determined the proportion of unnecessary trauma referrals and described the characteristics of this patient population. Methods: A retrospective chart review was carried out between 1 January and 31 December 2016. Data regarding demographics, diagnosis and clinical course at the ED were collected in standardised forms. A referral was defined as unnecessary if the patient was discharged from the ED without a therapeutic procedure performed. Results: There were 121 trauma referrals. The mean age was 39.0±18.3 years old, and 94 (77.7%) patients were male. Seventy-eight (64.5%) of the referrals were from EDs in the same health-care cluster. Overall, 15 (12.3%) referrals were unnecessary, and of these, nine patients had sustained burns or were suffering from smoke inhalation. The length of stay of these unnecessary referrals was 197.0±96.2 minutes. Referring ED outside the health-care cluster was significantly associated with unnecessary referrals (odds ratio=4.42, 95% confidence interval 1.40–13.97, p=0.007). Conclusion: More than 1 in 10 trauma referrals were unnecessary. Further collaborative prospective studies with other EDs are needed to elucidate the underlying reasons for such unnecessary referrals so that targeted solutions can be implemented to reduce them in the future.
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Affiliation(s)
- Chengjie Lee
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Paul Yugendra
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
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Wake E, Atkins H, Willock A, Hawkes A, Dawber J, Weir KA. Telehealth in trauma: A scoping review. J Telemed Telecare 2020; 28:412-422. [PMID: 32715866 DOI: 10.1177/1357633x20940868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this scoping review was to ascertain how 'telehealth' is utilised within health care, from pre hospital to admission, discharge and post discharge, with patients who have suffered major trauma. METHODS A scoping review of the literature published in English since 1980 was conducted using MEDLINE, Ovid EMBASE, PsychINFO, CINAHL, Austhealth, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane library) and Web of Science MEDLINE and MEBASE to identify relevant studies. RESULTS We included 77 eligible studies with both randomised controlled trial and cohort design methodology. A variety of trauma was included such as traumatic brain injuries (n = 52; 67.5%), spinal cord injury (n = 14; 18.2%) and multi-trauma (n = 9; 11.7%) to both adult (n = 38) and paediatric (n = 32) participants. Telehealth is used in pre-hospital and acute-care settings (n = 11; 14.3%) to facilitate assessment, and in rehabilitation and follow-up (n = 61; 79.2%) to deliver therapy. Effects on health were reported the most (n = 46), with no negative outcomes. The feasibility of telehealth as a delivery mode was established, but coordination and technical issues are barriers to use. Overall, both patients and clinicians were satisfied using this mode of delivery. CONCLUSION This review demonstrates how telehealth is utilised across a spectrum of patients with traumatic injuries and to facilitate delivery of therapy, specialist consultations and assessments, with many studies reporting improvements to health. There is a paucity of high-quality rigorous research, which makes replication of findings and uptake of the intervention problematic. Future telehealth and trauma research should focus on the quality and reproducibility of telehealth interventions and the economic feasibility of using this platform to deliver trauma care.
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Affiliation(s)
- Elizabeth Wake
- Gold Coast Hospital and Health Service, Australia.,Griffith University, Australia
| | - Heidi Atkins
- Clinical Excellence Queensland, Queensland Health, Australia
| | | | | | - Jessica Dawber
- Gold Coast Hospital and Health Service, Australia.,Menzies Health Institute, Australia
| | - Kelly A Weir
- Gold Coast Hospital and Health Service, Australia.,Menzies Health Institute, Australia
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13
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Morgan JM, Calleja P. Emergency trauma care in rural and remote settings: Challenges and patient outcomes. Int Emerg Nurs 2020; 51:100880. [PMID: 32622226 DOI: 10.1016/j.ienj.2020.100880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 04/16/2020] [Accepted: 05/07/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes. METHODS An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references. RESULTS 2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation. CONCLUSIONS The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.
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Affiliation(s)
- Janita M Morgan
- School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia; Gympie Hospital, Queensland Health, 12 Henry Street, Gympie 4570, QLD, Australia.
| | - Pauline Calleja
- School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia; School of Nursing Midwifery & Social Sciences, CQUniversity, Level 3 Cairns Square, Corner Abbott and Shields Street, Cairns 4870, QLD, Australia; Retrieval Services Queensland, Department of Health, 125 Kedron Park Road, Kedron 4031, QLD, Australia.
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14
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Martinelli M, Moroni D, Bastiani L, Mrakic-Sposta S, Giardini G, Pratali L. High-altitude mountain telemedicine. J Telemed Telecare 2020; 28:135-145. [PMID: 32539486 PMCID: PMC8915246 DOI: 10.1177/1357633x20921020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction An innovative teleconsultation platform has been designed, developed and validated between summer 2017 and winter 2018, in five mountain huts and in three remote outpatient clinical centres of the Italian region Valle d’Aosta of the Mont Blanc massif area. Methods An ad-hoc videoconference system was developed within the framework of the e-Rés@MONT (Interreg ALCOTRA) European project, to tackle general health problems and high-altitude diseases (such as acute mountain sickness, high-altitude pulmonary and cerebral oedema). The system allows for contacting physicians at the main hospital in Aosta to perform a specific diagnosis and to give specific advice and therapy to the patients in an extreme environment out-hospital setting. At an altitude between 1500–3500 m, five trained nurses performed clinical evaluations (anamnesis, blood pressure, heart rate, oxygen saturation), electrocardiographic and echography monitoring on both tourists and residents as necessary; all of the collected data were sent to the physicians in Aosta. Results A total of 702 teleconsultation cases were performed: 333 dismissed (47%), 356 observed (51%) and 13 immediate interventions (2%). In 30 cases the physicians decided there was no need for helicopter and ambulance rescue intervention and hospital admissions. The main physiological measures, the classified pathologies, the severe cases and the cost savings are described in this article. Discussion The e-Rés@MONT teleconsultation platform has been discussed in terms of treated cases, feasibility, proactivity in reducing complexities, direct and indirect advantages, and diagnostics help; moreover, general and specific pros and cons have been debated, and future steps have been exposed.
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Affiliation(s)
- Massimo Martinelli
- Institute of Information Science and Technologies, National Research Council of Italy, Italy
| | - Davide Moroni
- Institute of Information Science and Technologies, National Research Council of Italy, Italy
| | - Luca Bastiani
- Institute of Clinical Physiology, National Research Council, Italy
| | | | - Guido Giardini
- Mountain Medicine Centre, Valle d'Aosta Regional Hospital, Italy.,Montagne Sûre, Italy
| | - Lorenza Pratali
- Institute of Clinical Physiology, National Research Council, Italy.,Mountain Medicine Centre, Valle d'Aosta Regional Hospital, Italy.,Montagne Sûre, Italy
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Lapointe L, Lavallee-Bourget MH, Pichard-Jolicoeur A, Turgeon-Pelchat C, Fleet R. Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review. CANADIAN JOURNAL OF RURAL MEDICINE 2020; 25:31-40. [PMID: 31854340 DOI: 10.4103/cjrm.cjrm_8_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients. Materials and Methods A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies. Results The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients. Conclusions The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.
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Affiliation(s)
- Luc Lapointe
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Marie-Helene Lavallee-Bourget
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Alexia Pichard-Jolicoeur
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Catherine Turgeon-Pelchat
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Richard Fleet
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis; Department of Family and Emergency Medicine, Laval University; Centre De Recherche Sur Les Soins Et Services De Première Ligne Université Laval, Québec, Canada
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Lyria Hoa MH, Ong YKG, Pek JH. Trauma transfers to the pediatric emergency department - Is it necessary? Turk J Emerg Med 2020; 20:12-17. [PMID: 32355896 PMCID: PMC7189817 DOI: 10.4103/2452-2473.276379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES: Pediatric trauma patients presenting to general emergency departments (EDs) may be transferred to pediatric EDs for further management. Unnecessary transfers increase health-care costs, add to workload, and decrease satisfaction. We, therefore, aimed to evaluate the proportion of unnecessary pediatric trauma transfers and describe patient characteristics of these transfers at the pediatric ED. METHODS: A retrospective chart review of cases with trauma-related diagnoses was carried out from January to April 2017. Information regarding patient demographics, diagnosis, and clinical progress was collected. A transfer was defined as unnecessary if the patient was discharged from the pediatric ED without any therapeutic procedure performed. RESULTS: There were 117 cases of trauma transfers. The mean age was 8.3 ± 4.9 years, and 77 (65.8%) patients were male. Ninety-five (81.2%) transfers were from restructured hospitals. Thirty-one (26.5%) cases were admitted to the hospital. Thirty-four (29.1%) cases were unnecessary transfers. The length of stay in the ED for these transferred cases was 118.4 ± 87.1 min. Referring ED was not significantly associated with discharge (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 0.43–3.83, P = 0.792), discharge without any therapeutic procedure performed (OR: 1.47, 95% CI: 0.50–4.31, P = 0.591), or length of stay (mean difference: 22.3 min, 95% CI: 84.5–39.9, P = 0.471). CONCLUSION: About a third of trauma transfers were unnecessary. Further collaborative efforts would be necessary to further define the situation in different health-care settings and exact reasons elucidated so that targeted interventions could be implemented to improve pediatric trauma care.
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Affiliation(s)
- Min Hui Lyria Hoa
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Yong-Kwang Gene Ong
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
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17
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Abstract
OBJECTIVES Pediatric patients living in rural, underserved areas have reduced access to medical care. There is a lack of research describing the use of telemedicine (TM) for general pediatric emergency medicine (PEM). In 2013, we established the Child Ready Virtual Pediatric Emergency Department Telehealth Network (CR-VPED), a PEM TM consultation service serving rural hospitals across the state of New Mexico. The aim of this article is to describe our experience for 6 years (2013-2018). METHODS We describe the process of establishing the CR-VPED Telehealth Network. We reviewed all the TM consultations completed from June 22, 2013, to September 6, 2018. In our review, we focus on patient demographics, medical complaint, transfer status, type of referring provider, and problems encountered with each TM consultation. RESULTS We had a total of 58 PEM TM consultations between June 22, 2013, and September 6, 2018. All consultations occurred at 6 of the 12 established sites. Most TM consultations (71%; 41/58) were with Indian Health Service sites. Among all TM consultations, patients ranged in age from 30 days to 17 years (mean, 54 months; median, 32 months). Only 26% (15/58) of the patients with TM consultations were transferred to the tertiary care hospital. There was a heterogeneous mix of chief complaints and diagnoses. Rash was the most common chief complaint (24%; 14/58). There was a mix of referring providers, with family medicine physicians being most common (31%; 18/58). Common technical issues were not properly recording the encounter into the electronic medical record (12%; 7/58) and difficulty logging into the CR-VPED Telehealth Network (9%; 5/58). CONCLUSIONS Previous studies have investigated the use of TM in pediatric acute care, but most studies have focused on critical care or subspecialty care in the office setting. Our experience with CR-VPED has shown that it has been feasible to provide general pediatric emergency care to patients in underserved, rural emergency departments across New Mexico. Patients requiring TM consultation were heterogeneous in age and presentation.
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Tripod M, Tait M, Bracey J, Sexton K, Beck W, Wyrick TO. The Use of Telemedicine Decreases Unnecessary Hand Trauma Transfers. Hand (N Y) 2020; 15:422-427. [PMID: 30417694 PMCID: PMC7225886 DOI: 10.1177/1558944718810877] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: The Arkansas Hand Trauma Telemedicine Program (AHTTP) is a novel telemedicine system that was developed in 2014 within a rural state to address the growing need of access to hand trauma care with one trauma center that cares for mangling hand injuries. The purpose is to compare transfers for hand injuries prior to and after the implementation of this system. Methods: The hospital institutional database was queried for all transfers to a level 1 medical center in the state from 2012 to 2015, allowing the comparison of data prior to and after the institution of the AHTTP. Patient disposition from the emergency department was categorized to evaluate the impact of AHTTP. Distance, mode of transport, and transport cost were assessed. Findings: There were 202 transfers for the treatment of isolated hand trauma (92 from 2012 to 2013 and 110 from 2014 to 2015). Prior to the institution of AHTTP, transfer patients were admitted 47.8% of the time compared with 68.2% of the time after the development of the program (P = .02). The approximate cost of transport for patients who were discharged home directly from the emergency department was 38.5% (US $47,233) of the total costs for the 2012-2013 period and was 21.4% (US $34,017) of the costs for the 2014-2015 period (P < .0001). Conclusions: There was a statistically significant decrease in the number of unnecessary transfers and transportation costs after the telemedicine program was started. The implementation of AHTTP in a rural state reduced health care costs and improved the efficiency of hand specialty care.
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Affiliation(s)
- Morgan Tripod
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - Mark Tait
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - John Bracey
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - Kevin Sexton
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - William Beck
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - Theresa O. Wyrick
- University of Arkansas for Medical Sciences, Little Rock, USA,Theresa O. Wyrick, Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Slot 531, Little Rock, AR 72207, USA.
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Fleet R. A Canadian Rural Living Lab Hospital: Implementing solutions for improving rural emergency care. Future Healthc J 2020; 7:15-21. [PMID: 32104760 PMCID: PMC7032583 DOI: 10.7861/fhj.2019-0067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION More than 6 million Canadians live in rural areas (approximately 20% of the population) and emergency services are a critical safety net for them. OBJECTIVES We want to create, in Baie-Saint-Paul (rural emergency department, Québec, Canada), an experimental milieu where all stakeholders develop, implement and evaluate solutions to address the problems that beset their environment. METHOD The Living Lab will rely on the quadruple aim approach to improve health system performance and will use a multimethod approach based on the philosophy of open and user-driven innovation. Three pilot projects will be implemented (quality of work life programme, computed tomography implementation study and telemedicine in ambulances). Other possible solutions will be evaluated and prioritised (in situ simulation, care protocol, telemedicine, point-of-care ultrasound, helicopters and drones). CONCLUSION We are confident that this Living Lab will contribute to saving lives, will improve the quality of work life for rural healthcare professionals, and will inspire similar innovation internationally.
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Affiliation(s)
- Richard Fleet
- psychologist and associate professor, Laval University, Québec, Canada, endowed research chair of emergency medicine, Centre de recherche du CISSS Chaudière-Appalaches, Lévis, Canada and Centre de recherche sur les soins et services de première ligne de l’Université Laval, Québec, Canada
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20
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Van Gent JM, Davis KL, Henry N, Zander AL, Kuettel MA, Edson T, Nelson TJ, Tadlock MD. The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital. Mil Med 2019; 183:e494-e499. [PMID: 29635539 DOI: 10.1093/milmed/usy051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/06/2018] [Indexed: 11/14/2022] Open
Abstract
Introduction Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admissions before and after TCC implementation. Materials and methods Patient care by remote intensivist was achieved utilizing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC). Results Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre-TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified. Conclusion Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the operational readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted.
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Affiliation(s)
- Jan-Michael Van Gent
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA
| | - Konrad L Davis
- Department of Pulmonary and Critical Care Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA
| | - Nichole Henry
- Department of Nursing, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, CA
| | - Ashley L Zander
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA
| | - Matthew A Kuettel
- Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, CA
| | - Theodore Edson
- Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, CA
| | - Thomas J Nelson
- Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, CA
| | - Matthew D Tadlock
- Department of Surgery, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, CA
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Fleet R, Lauzier F, Tounkara FK, Turcotte S, Poitras J, Morris J, Ouimet M, Fortin JP, Plant J, Légaré F, Dupuis G, Turgeon-Pelchat C. Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centres in Quebec: a population-based, retrospective cohort study. BMJ Open 2019; 9:e028512. [PMID: 31160276 PMCID: PMC6549736 DOI: 10.1136/bmjopen-2018-028512] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES As Canada's second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings. DESIGN Retrospective cohort study. SETTING 26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada. PARTICIPANTS 79 957 trauma cases collected from Quebec's trauma registry. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality. RESULTS Overall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, p<0.001). After controlling for available potential confounders, the odds of prehospital or ED mortality were over three times greater for patients treated in a rural ED (OR 3.44, 95% CI 1.88 to 6.28). Trauma care setting (rural vs urban) was not associated with in-hospital mortality. Nearly all of the specialised services evaluated were more present at urban trauma centres. CONCLUSIONS Trauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.
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Affiliation(s)
- Richard Fleet
- Médecine familiale et médecine d’urgence, Universite Laval, Quebec, Canada
- Centre de recherche du CISSS Chaudière-Appalaches, Chaire de recherche en médecine d’urgence ULaval - CISSS Chaudière-Appalaches, Lévis, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval, Quebec, Canada
- Department of Anesthesiology and Critical Care Medicine, Universite Laval, Quebec, Canada
| | - Fatoumata Korinka Tounkara
- Centre de recherche du CISSS Chaudière-Appalaches, Chaire de recherche en médecine d’urgence ULaval - CISSS Chaudière-Appalaches, Lévis, Canada
| | - Stéphane Turcotte
- Centre de recherche du CISSS Chaudière-Appalaches, CISSS Chaudière-Appalaches, Lévis, Canada
| | | | - Judy Morris
- Emergency Medicine department, HSCM, Montreal, Canada
| | | | - Jean-Paul Fortin
- Centre integre universitaire de sante et de services sociaux de la Capitale-Nationale, Quebec, Canada
| | - Jeff Plant
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - France Légaré
- Family and Emergency Medicine, Université Laval, Québec, Canada
| | - Gilles Dupuis
- Psychology, Université du Québec à Montréal, Montreal, Canada
| | - Catherine Turgeon-Pelchat
- Centre de recherche du CISSS Chaudière-Appalaches, Chaire de recherche en médecine d’urgence ULaval - CISSS Chaudière-Appalaches, Lévis, Canada
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Natafgi N, Mohr NM, Wittrock A, Bell A, Ward MM. The Association Between Telemedicine and Emergency Department (ED) Disposition: A Stepped Wedge Design of an ED-Based Telemedicine Program in Critical Access Hospitals. J Rural Health 2019; 36:360-370. [PMID: 31013552 DOI: 10.1111/jrh.12370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/17/2019] [Accepted: 03/11/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Nabil Natafgi
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa.,Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
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Bukur M, Teurel C, Catino J, Kurek S. The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center. Am Surg 2018. [DOI: 10.1177/000313481808400854] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.
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Affiliation(s)
- Marko Bukur
- Division of Acute Care Surgery, Bellevue Hospital Center, NYU School of Medicine, New York, New York
| | - Candace Teurel
- Division of Trauma and Surgical Critical Care, Department of Surgery, Delray Medical Center, Delray Beach, Florida
| | - Joseph Catino
- Division of Trauma and Surgical Critical Care, Department of Surgery, Delray Medical Center, Delray Beach, Florida
| | - Stanley Kurek
- Baylor Scott & White Health, Temple, Texas
- Division of Acute Care Surgery, Texas A&M Health Science Center College of Medicine, Bryan, Texas
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24
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Crumley I, Blom L, Laflamme L, Alvesson HM. What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care. BMC Med Inform Decis Mak 2018; 18:71. [PMID: 30068341 PMCID: PMC6090944 DOI: 10.1186/s12911-018-0647-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 06/27/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Traumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology. METHODS This qualitative study investigated tele-experts' (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis. RESULTS Experts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback. CONCLUSION Experts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success - time pressure, intensity and the wide range of subspecialties to be considered.
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Affiliation(s)
- Iona Crumley
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, SE-171 77 Stockholm, Sweden
| | - Lisa Blom
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, SE-171 77 Stockholm, Sweden
| | - Lucie Laflamme
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, SE-171 77 Stockholm, Sweden
| | - Helle Mölsted Alvesson
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, SE-171 77 Stockholm, Sweden
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Abstract
Background Veterans with type 1 diabetes who live in rural Alabama and Georgia face barriers to receiving specialty diabetes care because of a lack of endocrinologists in the Central Alabama Veterans Health Care System. Telemedicine is a promising solution to help increase access to needed health care. We evaluated telemedicine’s effectiveness in delivering endocrinology care from Atlanta-based endocrinologists. Methods We conducted a retrospective chart review of patients who were enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. Outcomes of interest were hemoglobin A1c levels, changes in glycemic control, time savings for patients, cost savings for the US Veterans Health Administration, appointment adherence rates, and patient satisfaction with telehealth. Results Thirty-two patients with type 1 diabetes received telehealth care and in general received the recommended processes of diabetes care. Patients trended toward a decrease in mean hemoglobin A1c and glucose variability and a nonsignificant increase in hypoglycemic episodes. Patients saved 78 minutes of travel time (one way), and the VA saved $72.94 in travel reimbursements per patient visit. Patients adhered to 88% of scheduled telehealth appointments on average, and 100% of surveyed patients stated they would recommend telehealth to other veterans. Conclusions Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.
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Affiliation(s)
- Timothy Xu
- Mayo Clinic School of Medicine, 200 1st St SW, Rochester, MN 55905. .,Emory University, Atlanta, Georgia
| | | | - Sarah Sutton
- Central Alabama Veterans Health Care System, Montgomery, Alabama
| | - Mary Rhee
- Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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26
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To See or Not to See: Telemedicine's Impact on Triage Outcomes. Pediatr Crit Care Med 2017; 18:1081-1083. [PMID: 29099455 DOI: 10.1097/pcc.0000000000001326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Medford-Davis LN, Holena DN, Karp D, Kallan MJ, Delgado MK. Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury. Am J Emerg Med 2017; 36:797-803. [PMID: 29055613 DOI: 10.1016/j.ajem.2017.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/07/2017] [Accepted: 10/09/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation. METHODS We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures. RESULTS In 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6-8.2), head (OR 3.7, 95%CI 3.1-4.6), facial (OR 3.8, 95%CI 3.1-4.7), or hand (OR 3.1, 95%CI 2.6-3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2-1.5) or uninsured (OR 1.3, 95%CI 1.2-1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750-$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities. CONCLUSION Over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.
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Affiliation(s)
- Laura N Medford-Davis
- Department of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, United States.
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
| | - David Karp
- University of Pennsylvania Wharton Geographic Information Systems Lab, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - Michael J Kallan
- University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - M Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 933 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
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28
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Emergency Medical Service Concepts in Tehran, Iran. JOURNAL OF ORTHOPEDIC AND SPINE TRAUMA 2017. [DOI: 10.5812/jost.80778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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29
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Abstract
Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.
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Affiliation(s)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, CA 94305,California Perinatal Quality Care Collaborative, Stanford, CA 94305
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30
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Mohr NM, Vakkalanka JP, Harland KK, Bell A, Skow B, Shane DM, Ward MM. Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients. Telemed J E Health 2017; 24:194-202. [PMID: 28731843 DOI: 10.1089/tmj.2017.0083] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas M Mohr
- 1 Department of Emergency Medicine, University of Iowa College of Medicine , Iowa City, Iowa.,2 Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine , Iowa City, Iowa.,3 Department of Epidemiology, University of Iowa College of Public Health , Iowa City, Iowa
| | - J Priyanka Vakkalanka
- 1 Department of Emergency Medicine, University of Iowa College of Medicine , Iowa City, Iowa.,3 Department of Epidemiology, University of Iowa College of Public Health , Iowa City, Iowa
| | - Karisa K Harland
- 1 Department of Emergency Medicine, University of Iowa College of Medicine , Iowa City, Iowa
| | | | - Brian Skow
- 4 Avera eCARE , Sioux Falls, South Dakota
| | - Dan M Shane
- 5 Department of Health Management and Policy, University of Iowa College of Public Health , Iowa City, Iowa
| | - Marcia M Ward
- 5 Department of Health Management and Policy, University of Iowa College of Public Health , Iowa City, Iowa
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31
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Madiraju SK, Catino J, Kokaram C, Genuit T, Bukur M. In by helicopter out by cab: the financial cost of aeromedical overtriage of trauma patients. J Surg Res 2017; 218:261-270. [PMID: 28985859 DOI: 10.1016/j.jss.2017.05.102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/12/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Helicopter transport of injured patients is controversial and costly. This study aims to show that a complex trauma algorithm leads to significant aeromedical overtriage at substantial cost. Our secondary outcomes were to compare adjusted mortality and outcomes between air and ground transport and determine predictors of overtriage. MATERIALS AND METHODS A 6-y retrospective analysis was conducted of all trauma activations at a Level I center. Patients were dichotomized by transportation method as well as trauma activation criteria. Overtriage was defined as those who were discharged from the emergency department, medically admitted without injuries, or admitted to observation status only. Overtriage and associated charges were calculated for each patient cohort, and multivariate regression models were created to derive adjusted mortality rates and predictors of overtriage. RESULTS A total of 4218 patients were treated with 28% arriving by helicopter. Overtriage increased significantly from 51% to 77% with lower tier activation criteria (P < 0.001). Median charges for air-evacuated patients was $10,478 (versus $1008 ground). Eliminating overtriage of air patients would result in a cost savings of $1,316,036 annually. Adjusted mortality between air and ground transport was not significantly different (8.5% versus 10.9%, P = 0.548). Predictors of overtriage included decreasing age, Injury Severity Score, Head Abbreviated Injury Score, nonoperative treatment, and lower tier activation criteria. CONCLUSIONS Significant overtriage (52%) and unnecessary air evacuation of minimally injured patients occurs at great financial cost. Revision of trauma activation protocols may result in more judicious air transport use and significant reductions in health care costs.
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Affiliation(s)
| | - Joseph Catino
- Trauma/Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Candace Kokaram
- Trauma/Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Thomas Genuit
- FAU Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Marko Bukur
- Trauma/Critical Care, Bellevue Hospital Center, New York, New York
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32
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Abstract
BACKGROUND Pediatric interhospital transfers are an economic burden to the health care, especially when deemed unnecessary. Physicians may be unaware of the cost implications of pediatric emergency transfers. A cost analysis may be relevant to reduce cost. OBJECTIVE To characterize children transferred from outlying emergency departments (EDs) to pediatric ED (PED) with a specific focus on transfers who were discharged home in 12 hours or less after transfer without intervention in PED and analyze charges associated with them. METHODS Charts of 352 patients (age, 0-18 years) transferred from 31 outlying EDs to PED during July 2009 to June 2010 were reviewed. Data were collected on the range, unit charge and volume of services provided in PED, length of stay, and final disposition. The average charge per patient transfer is calculated based on unit charge times total service units per 1000 patients per year and divided by 1000. Hospital charges were divided into fixed and variable. RESULTS Of 352 patients transferred, 108 (30.7%) were admitted to pediatric inpatient service, 42 (11.9%) to intensive care; 36 (10.2%) went to the operating room, and 166 (47.2%) were discharged home. The average hospital charge per transfer was US $4843. Most (89%) of the charges were fixed, and 11% were variable. One hundred one (28.7%) patients were discharged home from PED in 12 hours or less without intervention. The hospital charges for these transfers were US $489,143. CONCLUSIONS Significant number of transfers was discharged 12 hours or less without any additional intervention in PED. Fixed charges contribute to majority of total charges. Cost saving can be achieved by preventing unnecessary transfer.
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Natafgi N, Shane DM, Ullrich F, MacKinney AC, Bell A, Ward MM. Using tele-emergency to avoid patient transfers in rural emergency departments: An assessment of costs and benefits. J Telemed Telecare 2017; 24:193-201. [DOI: 10.1177/1357633x17696585] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Tele-emergency can address several challenges facing emergency departments in rural areas. The purpose of this paper is to (a) examine the rates of avoided transfers in rural emergency departments that adopted tele-emergency applications; and (b) estimate the costs and benefits of using tele-emergency to avoid transfers. Methods Analysis is based on 9048 tele-emergency encounters generated by the Avera eEmergency programme (Sioux Falls, South Dakota) in 85 rural hospitals across seven states between October 2009–February 2014. For each non-transfer patient, physicians indicated whether the transfer was avoided because of tele-emergency activation. The cost-benefit analysis is conducted from the hospital, patient and societal perspectives, and includes technology costs, local hospital revenues and patient-associated savings. All monetary values are expressed in US$. Sensitivity analysis is conducted by examining the worst and best case scenarios of costs, revenues and savings. Results In these analyses, 1175 avoided transfers were attributed to tele-emergency. From a rural hospital perspective, tele-emergency costs around US$1739 to avoid a single transfer. However, tele-emergency saves around US$5563 in avoided transportation and indirect patient costs. Combining these, from a societal perspective, tele-emergency has the potential to result in a net savings of US$3823 per avoided transfer while accounting for tele-emergency technology costs, hospital revenues, and patient-associated savings. Conclusion This study highlights various stakeholder perspectives on the financial impact of tele-emergency in avoiding patient transfers in rural emergency departments. Telemedicine has the potential to reduce the number of transfers of emergency department patients and generate some revenue for rural hospitals despite associated technology costs, while incurring substantial patient savings.
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Affiliation(s)
- Nabil Natafgi
- Department of Health Management and Policy, University of Iowa, USA
| | - Dan M Shane
- Department of Health Management and Policy, University of Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy, University of Iowa, USA
| | | | | | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa, USA
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Mohr NM, Harland KK, Chrischilles EA, Bell A, Shane DM, Ward MM. Emergency Department Telemedicine Is Used for More Severely Injured Rural Trauma Patients, but Does Not Decrease Transfer: A Cohort Study. Acad Emerg Med 2017; 24:177-185. [PMID: 28187248 DOI: 10.1111/acem.13120] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/29/2016] [Accepted: 10/11/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient-level factors associated with telemedicine consultation in North Dakota critical-access hospital (CAH) emergency departments (EDs) and to measure the association between telemedicine consultation and interhospital transfer. METHODS Observational cohort study of all adult (age ≥ 18 years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors. RESULTS Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio = 1.28, 95% confidence interval = 0.94 to 1.75). CONCLUSION Emergency department-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions.
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Affiliation(s)
- Nicholas M. Mohr
- Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA
- Division of Critical Care Department of Anesthesia University of Iowa Carver College of Medicine Iowa City IA
| | - Karisa K. Harland
- Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA
| | | | | | - Dan M. Shane
- Department of Health Management and Policy University of Iowa College of Public Health Iowa City IA
| | - Marcia M. Ward
- Department of Health Management and Policy University of Iowa College of Public Health Iowa City IA
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Abstract
Telemedicine is increasingly becoming an important part of the health care system as it has the potential to help deliver quality medical care to underserved areas. When implemented correctly, it can be a cost-effective way of expanding access to excellent medical care. However, because it is a relatively new and quickly changing field, there are multiple issues and challenges that need to be addressed. This article reviews the current literature on various modalities of telemedicine, evidence for teletrauma, and challenges and barriers related to telemedicine.
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Affiliation(s)
- Paul T Kim
- Department of General Surgery, University of Cincinnati Medical Center, Cincinnati Children׳s Hospital Medical Center, Cincinnati, Ohio
| | - Richard A Falcone
- Division of Pediatric and Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, Cincinnati, Ohio.
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36
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Abstract
Telemedicine has been successfully used in many areas of medicine, including triage and evaluation of the acute burn patient. The utility of telemedicine during the rehabilitative phase of burn care has yet to be evaluated; therefore, we expanded our telemedicine program to link our burn center with a rehabilitation facility. The goal of this project was to demonstrate cost-effective improvements in the transition and quality of care. A retrospective review was performed on all patients enrolled in our telemedicine/rehabilitation program between March 2013 and March 2014. Data collected included total number of encounters, visits, type of visit, physician time, and readmissions. Transportation costs were based on local ambulance rates between the two facilities. The impact of telemedicine was evaluated with respect to the time saved for the physician, burn center, and burn clinic, as well as rehabilitative days saved. A patient satisfaction survey was also administered. A total of 29 patients participated in 73 virtual visits through the telemedicine project. Virtual visits included new consults, preoperative evaluations, and postoperative follow-ups. A total of 146 ambulance transports were averted during the study period, totaling $101,110. Virtual visits saved 6.8 outpatient burn clinic days, or 73 clinic appointments of 30-min duration. The ability to perform more outpatient surgery resulted in 80 inpatient bed days saved at the burn hospital. The rehabilitation hospital saved an average of 2 to 3 patient days secondary to unnecessary travel. Satisfaction surveys demonstrated patient satisfaction with the encounters, primarily related to time saved. The decrease in travel time for the patient from the rehabilitation hospital to outpatient burn clinic improved adherence to the rehabilitation care plan and resulted in increased throughput at the rehabilitation facility. Videoconferencing between a burn center and rehabilitation hospital streamlined patient care and reduced health care costs, while maintaining quality of care and patient satisfaction. This program has improved inpatient burn rehabilitation by maximizing time spent in therapy and avoiding unnecessary patient travel to offsite appointments.
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37
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Hoseini F, Ayatollahi H, Salehi SH. systematized review of telemedicine applications in treating burn patients. Med J Islam Repub Iran 2016; 30:459. [PMID: 28491834 PMCID: PMC5419220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/19/2016] [Indexed: 11/17/2022] Open
Abstract
Background: Telemedicine has been used in different fields of medicine in the past 20 years. The main advantages of this technology include saving costs, improving quality of care, and increasing access to specialists. This study aimed to review telemedicine applications in treating burn patients. Methods: In this systematized review study, related papers were searched using various databases, including PubMed, Scopus, and Science Direct. The time frame was between January 2000 and March 2016; finally, 32 papers were included in the study. Results: The findings revealed that telemedicine was used in burn care in three different ways: Remote patient follow-up, teleconsultation, and patient assessment. Conclusion: It seems that telemedicine can be easily applied in treating burn patients even when there is a limited financial resource. The use of this technology can help reduce possible errors in categorizing burn patients and decrease patients' transportation and treatment costs.
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Affiliation(s)
- Frahang Hoseini
- MSc in Medical Informatics, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Haleh Ayatollahi
- Assistant Professor of Medical Informatics, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Seyed Hamid Salehi
- Associate Professor of General Surgery, Iran University of Medical Sciences, Tehran, Iran.
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A systematic review of the methodologies used to evaluate telemedicine service initiatives in hospital facilities. Int J Med Inform 2016; 97:171-194. [PMID: 27919377 DOI: 10.1016/j.ijmedinf.2016.10.012] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 09/30/2016] [Accepted: 10/12/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The adoption of telemedicine into mainstream health services has been slower than expected. Many telemedicine projects tend not to progress beyond the trial phase; there are a large number of pilot or project publications and fewer 'service' publications. This issue has been noted since 1999 and continues to be acknowledged in the literature. While overall telemedicine uptake has been slow, some services have been successful. The reporting and evaluation of these successful services may help to improve future uptake and sustainability. The aim of this literature review was to identify peer-reviewed publications of deployed telemedicine services in hospital facilities; and to report, and appraise, the methodology used to evaluate these services. METHODS Computerised literature searches of bibliographic databases were performed using the MeSH terms for "Telemedicine" and "Hospital Services" or "Hospital", for papers published up to May 2016. RESULTS A total of 164 papers were identified, representing 137 telemedicine services. The majority of reported telemedicine services were based in the United States of America (n=61, 44.5%). Almost two thirds of the services (n=86, 62.7%) were delivered by real time telemedicine. Of the reviewed studies, almost half (n=81, 49.3%) assessed their services from three different evaluation perspectives: clinical outcomes, economics and satisfaction. While the remaining half (n=83, 50.6%) described their service and its activities without reporting any evaluation measures. Only 30 (18.2%) studies indicated a two-step implementation and evaluation process. There was limited information in all reported studies regarding description of a structured planning strategy. CONCLUSION Our systematic review identified only 137 telemedicine services. This suggests either telemedicine service implementation is still not a part of mainstream clinical services, or it is not being reported in the peer-reviewed literature. The depth and the quality of information were variable across studies, reducing the generalisability. The reporting of service implementation and planning strategies should be encouraged. Given the fast paced technology driven environment of telemedicine, this may enable others to learn and understand how to implement sustainable services. The key component of planning was underreported in these studies. Studies applying and reporting more rigorous methodology would contribute greatly to the evidence for telemedicine.
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Zennaro F, Neri E, Nappi F, Grosso D, Triunfo R, Cabras F, Frexia F, Norbedo S, Guastalla P, Gregori M, Cattaruzzi E, Sanabor D, Barbi E, Lazzerini M. Real-Time Tele-Mentored Low Cost "Point-of-Care US" in the Hands of Paediatricians in the Emergency Department: Diagnostic Accuracy Compared to Expert Radiologists. PLoS One 2016; 11:e0164539. [PMID: 27749905 PMCID: PMC5066956 DOI: 10.1371/journal.pone.0164539] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 09/27/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The use of point-of-care ultrasonography (POC US) in paediatrics is increasing. This study investigated the diagnostic accuracy of POC US in children accessing the emergency department (ED) when performed by paediatricians under the remote guidance of radiologists (TELE POC). METHODS Children aged 0 to 18 years accessing the ED of a third level research hospital with eight possible clinical scenarios and without emergency/severity signs at the triage underwent three subsequent US tests: by a paediatrician guided remotely by a radiologist (TELE POC); by the same radiologist (UNBLIND RAD); by an independent blinded radiologist (BLIND RAD). Tele-radiology was implemented using low cost "commercial off-the-shelf" (COTS) equipment and open-source software. Data were prospectively collected on predefined templates. RESULTS Fifty-two children were enrolled, for a total of 170 ultrasound findings. Sensitivity, specificity, positive and negative predictive values of TELE POC were: 93.8, 99.7, 96.8, 99.4 when compared to UNBLIND RAD and 88.2, 99.7, 96.8, 98.7 when compared to BLIND RAD. The inter-observers agreement between the paediatricians and either the unblind or blind radiologist was excellent (k = 0.93). The mean duration of TELE POC was 6.3 minutes (95% CI 4.1 to 8.5). Technical difficulties occurred in two (3.8%) cases. Quality of the transmission was rated as fair, good, very good and excellent in 7.7%, 15.4%, 42.3% and 34.6% of cases respectively, while in no case was it rated as poor. CONCLUSIONS POC US performed by paediatricians in ED guided via tele-radiology by an expert radiologist (TELE POC) produced reliable and timely diagnoses. Findings of this study, especially for the rarer conditions under evaluation, need further confirmation. Future research should investigate the overall benefits and the cost savings of using tele-ultrasound to perform US "at children's bedsides", under remote guidance of expert radiologists.
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Affiliation(s)
- Floriana Zennaro
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Elena Neri
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | | | - Daniele Grosso
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | | | | | | | - Stefania Norbedo
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Pierpaolo Guastalla
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Massino Gregori
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Elisabetta Cattaruzzi
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Daniela Sanabor
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
| | - Marzia Lazzerini
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo”, Via dell’istria 65/1, Trieste, Italy
- * E-mail:
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Broman KK, Poulose BK, Phillips SE, Ehrenfeld JM, Sharp KW, Pierce RA, Holzman MD. Unnecessary Transfers for Acute Surgical Care: Who and Why? Am Surg 2016. [DOI: 10.1177/000313481608200823] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Interhospital transfers for acute surgical care occur commonly, but without clear guidelines or protocols. Transfers may subject patients and delivery systems to significant burdens without clear clinical benefit. The incidence and factors associated with unnecessary transfers are not well described. We conducted a retrospective cohort study of patient transfers within a regional referral network to a tertiary center for nontrauma acute surgical care from 2009 to 2013. Clinically unnecessary transfers were defined as transfers that resulted in no intervention (operation, endoscopy, or interventional radiology procedure) and discharge to home within 72 hours. We performed bivariate and multivariate logistic regression analyses. The study population included 2177 patient transfers, 19 per cent of which were determined to be clinically unnecessary. After adjustment, clinically unnecessary transfers were more commonly performed for patient request (odds ratio = 2.52, 95% confidence interval = 1.60–3.99), continuity of care (1.87, 1.44–2.42), and care by urologic (1.50, 1.06–2.13) and vascular services (1.44, 1.03–2.01). Patients with higher comorbidity and severity of illness scores were less likely to have unnecessary transfers. The burden of unnecessary transfers could be mitigated by identifying appropriate transfer candidates through mutually developed guidelines, interfacility collaboration, and increased use of remote care to provide surgical subspecialty consultation and maintain continuity.
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Affiliation(s)
- Kristy Kummerow Broman
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Benjamin K. Poulose
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon E. Phillips
- Departments of Biostatistics Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M. Ehrenfeld
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
- Departments of Anesthesiology Vanderbilt University Medical Center, Nashville, Tennessee
- Departments of Bioinformatics Vanderbilt University Medical Center, Nashville, Tennessee
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenneth W. Sharp
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard A. Pierce
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D. Holzman
- Departments of Surgery Vanderbilt University Medical Center, Nashville, Tennessee
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Ye J, Zuo Y, Xie T, Wu M, Ni P, Kang Y, Yu X, Sun X, Huang Y, Lu S. A telemedicine wound care model using 4G with smart phones or smart glasses: A pilot study. Medicine (Baltimore) 2016; 95:e4198. [PMID: 27495023 PMCID: PMC4979777 DOI: 10.1097/md.0000000000004198] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
To assess the feasibility of a wound care model using 4th-generation mobile communication technology standards (4G) with smart phones or smart glasses for wound management.This wound care model is an interactive, real-time platform for implementing telemedicine changing wound dressings, or doing operations. It was set up in March 2015 between Jinhua in Zhejiang province and Shanghai, China, which are 328 km apart. It comprised of a video application (APP), 4G net, smart phones or smart glasses, and a central server.This model service has been used in 30 patients with wounds on their lower extremities for 109 times in 1 month. Following a short learning curve, the service worked well and was deemed to be user-friendly. Two (6.7%) patients had wounds healed, while others still required wound dressing changes after the study finished. Both local surgeons and patients showed good acceptance of this model (100% and 83.33%, respectively).This telemedicine model is feasible and valuable because it provides an opportunity of medical service about wound healing in remote areas where specialists are scarce.
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Affiliation(s)
- Junna Ye
- Institute of Burns, Ruijin Hospital
| | | | - Ting Xie
- Department of Wound Healing, Shanghai Ninth Hospital, School of Medicine,Shanghai Jiao Tong University, Shanghai, China
| | - Minjie Wu
- Department of Wound Healing, Shanghai Ninth Hospital, School of Medicine,Shanghai Jiao Tong University, Shanghai, China
| | - Pengwen Ni
- Department of Wound Healing, Shanghai Ninth Hospital, School of Medicine,Shanghai Jiao Tong University, Shanghai, China
| | | | | | - Xiaofang Sun
- Department of Wound Healing, Shanghai Ninth Hospital, School of Medicine,Shanghai Jiao Tong University, Shanghai, China
| | | | - Shuliang Lu
- Institute of Burns, Ruijin Hospital
- Correspondence: Shuliang Lu, Institute of Burns, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, No.197 Rui Jin 2nd Road, Shanghai 200025, China (e-mail: )
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Tarighi P, Sherman JE, Mian O, Nathens AB. The importance of tailoring physicians' trauma care training needs in rural environments. Can J Surg 2016; 58:423-5. [PMID: 26424686 DOI: 10.1503/cjs.002315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
SUMMARY Gaps in the provision of care exist in the initial evaluation and management of patients first cared for in the most rural settings. We designed a survey to explore what unmet educational needs might exist so as to improve the care of patients before transfer. Here we discuss opportunities for tailored training that will enhance learning capacity, narrow the trauma education gap and improve trauma care, particularly in rural environments.
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Affiliation(s)
- Payam Tarighi
- From the Sunnybrook Health Sciences Centre, Toronto, Ont. (Tarighi, Nathens); the Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ont. (Sherman, Mian); and the Department of Surgery, University of Toronto, Toronto, Ont. (Nathens)
| | - Jill E Sherman
- From the Sunnybrook Health Sciences Centre, Toronto, Ont. (Tarighi, Nathens); the Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ont. (Sherman, Mian); and the Department of Surgery, University of Toronto, Toronto, Ont. (Nathens)
| | - Oxana Mian
- From the Sunnybrook Health Sciences Centre, Toronto, Ont. (Tarighi, Nathens); the Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ont. (Sherman, Mian); and the Department of Surgery, University of Toronto, Toronto, Ont. (Nathens)
| | - Avery B Nathens
- From the Sunnybrook Health Sciences Centre, Toronto, Ont. (Tarighi, Nathens); the Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ont. (Sherman, Mian); and the Department of Surgery, University of Toronto, Toronto, Ont. (Nathens)
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Abstract
OBJECTIVE The aim of this study was to review current literature relating to telemedicine in pediatric emergency medicine including its clinical applications and challenges associated with its implementation. METHODS We reviewed the literature using standard search methods in accordance with preferred reporting items for systematic reviews and meta-analysis. We included the studies done in emergency settings for all age groups and narrowed our search to the articles that are relevant to "impact on quality of care" and "patient outcome." We also described current telemedicine uses, software, hardware, and other requirements needed for pediatric emergency applications. RESULTS Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve quality of care for children. Logistic and legal challenges exist for pediatric emergency medicine applications similar to its uses in other settings. CONCLUSIONS Current frameworks exist in the use of telemedicine for pediatric emergency medicine. Research is still needed to see whether clinical outcomes are improved with pediatric emergency telemedicine solutions. Practical issues regarding training, accessibility, and resource allocation should be explored as pediatric emergency telemedicine evolves.
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Steinman M, Morbeck RA, Pires PV, Abreu Filho CAC, Andrade AHV, Terra JCC, Teixeira Junior JC, Kanamura AH. Impact of telemedicine in hospital culture and its consequences on quality of care and safety. ACTA ACUST UNITED AC 2015; 13:580-6. [PMID: 26676268 PMCID: PMC4878634 DOI: 10.1590/s1679-45082015gs2893] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 04/29/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice. METHODS The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein. RESULTS Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis. CONCLUSION The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.
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Mueller KJ, Potter AJ, MacKinney AC, Ward MM. Lessons from tele-emergency: improving care quality and health outcomes by expanding support for rural care systems. Health Aff (Millwood) 2015; 33:228-34. [PMID: 24493765 DOI: 10.1377/hlthaff.2013.1016] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tele-emergency services provide immediate and synchronous audio/video connections, most commonly between rural low-volume hospitals and an urban "hub" emergency department. We performed a systematic literature review to identify tele-emergency models and outcomes. We then studied a large tele-emergency service in the upper Midwest. We sent a user survey to all seventy-one hospitals that used the service and received 292 replies. We also conducted telephone interviews and site visits with ninety clinicians and administrators at twenty-nine of these hospitals. Participants reported that tele-emergency improves clinical quality, expands the care team, increases resources during critical events, shortens time to care, improves care coordination, promotes patient-centered care, improves the recruitment of family physicians, and stabilizes the rural hospital patient base. However, inconsistent reimbursement policy, cross-state licensing barriers, and other regulations hinder tele-emergency implementation. New value-based payment systems have the potential to reduce these barriers and accelerate tele-emergency expansion.
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Prescher H, Grover E, Mosier J, Stolz U, Biffar DE, Hamilton AJ, Sakles JC. Telepresent Intubation Supervision Is as Effective as In-Person Supervision of Procedurally Naive Operators. Telemed J E Health 2015; 21:170-5. [DOI: 10.1089/tmj.2014.0090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hannes Prescher
- College of Medicine, University of Arizona, Tucson, Arizona
- Arizona Simulation Technology and Education Center, University of Arizona, Tucson, Arizona
| | - Emily Grover
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - Jarrod Mosier
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Uwe Stolz
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - David E. Biffar
- Arizona Simulation Technology and Education Center, University of Arizona, Tucson, Arizona
| | - Allan J. Hamilton
- Arizona Simulation Technology and Education Center, University of Arizona, Tucson, Arizona
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - John C. Sakles
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
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Amadi-Obi A, Gilligan P, Owens N, O'Donnell C. Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment. Int J Emerg Med 2014; 7:29. [PMID: 25635190 PMCID: PMC4306051 DOI: 10.1186/s12245-014-0029-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 06/19/2014] [Indexed: 12/22/2022] Open
Abstract
The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.
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Affiliation(s)
- Ahjoku Amadi-Obi
- Clinical Research Department, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland ; Emergency Department, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - Peadar Gilligan
- Emergency Department, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - Niall Owens
- School of Medicine, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland
| | - Cathal O'Donnell
- National Ambulance Services, Oak House, Millennium Park, Naas, County Kildare, Ireland
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Gilman M, Stensland J. Telehealth and Medicare: payment policy, current use, and prospects for growth. MEDICARE & MEDICAID RESEARCH REVIEW 2013; 3:mmrr.003.04.a04. [PMID: 24834368 PMCID: PMC4011650 DOI: 10.5600/mmrr.003.04.a04] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Evaluate the growth in various types of Medicare-paid telehealth services. BACKGROUND There has been a long-standing hope that telehealth could be used to reduce rural patients' travel times to specialty physicians. Medicare covers telehealth services provided through live, interactive videoconferencing between a beneficiary located at a certified rural site and a distant practitioner. METHODS We analyzed 100% of telehealth Medicare claims for 2009 matched to individual patient ZIP codes and individual provider characteristics. RESULTS Despite increases in Medicare payment rates for telehealth services, expansions of covered services, reductions in provider requirements, and provisions of federal grants to encourage telehealth, growth in adoption of telehealth among providers has been modest. Medicare claims indicate that only 369 providers had 10 or more Medicare telehealth consultations in 2009. Roughly half of the 369 were mental health professionals, and about one-in-five of the 369 were non-physician professionals (e.g., physician assistants and nurse practitioners). On balance, the strong areas of telehealth are mental health and, surprisingly, nonphysician professionals. The comparative advantage of mental health could be the verbal (rather than physical contact) nature of mental health care, and the comparative advantage of non-physician professionals could be their lower labor costs.
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