Utilizing Telemedicine in a Novel Approach to COVID-19 Management and Patient Experience in the Emergency Department

Background: The COVID-19 crisis has highlighted telemedicine as a care delivery tool uniquely suited for a disaster pandemic. Introduction: With support from emergency department (ED) leadership, our institution rapidly deployed telemedicine in a novel approach to large-scale ED infectious disease management at NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCMC) and NewYork-Presbyterian/Lower Manhattan Hospital (NYP/LMH). Materials and Methods: Nineteen telemedicine carts were placed in COVID-19 isolation rooms to conserve personal protective equipment (PPE) and mitigate infectious risk for patients and providers by decreasing in-person exposures. Results: The teleisolation carts were used for 261 COVID-19 patient interactions from March to May 2020, with 79% of overall use in March. Our urban academic site (NYP/WCMC) had 173 of these cases, and the urban community hospital (NYP/LMH) had 88. This initiative increased provider/patient communication and attention to staff safety, improved palliative care and patient support services, lowered PPE consumption, and streamlined clinical workflows. The carts also increased patient comfort and reduced the psychological toll of isolation. Discussion: Deploying customized placement strategies in these two EDs maximized cart availability for isolation patients and demonstrates the utility of telemedicine in various ED settings. Conclusions: The successful introduction of this program in both academic and urban community hospitals suggests that widespread adoption of similar initiatives could improve safe ED evaluation of potentially infectious patients. In the longer term, our experience underscores the critical role of telemedicine in disaster preparedness planning, as building these capabilities in advance allows for the agile scaling needed to manage unforeseen catastrophic scenarios.

Evaluation of Usability, Perception of Usefulness, and Efficiency of an Application in Interpreting Imaging Examinations and Supporting Decision-Making in Orthopedics

Background: Medical smartphone applications have rendered positive results in daily practice and also serve as potentially valuable educational tools. In orthopedics, radiograph analysis and angle measurements comprise an essential mechanism in the diagnosis, treatment, planning, and evaluation of the results in orthopedic surgery. Purpose: Thus, the present study aimed to evaluate an application for mobile devices for orthopedic doctors and orthopedic residents. The application proposes the analysis and interpretation of radiographic imaging examinations through assessments and angle measurements. In this survey, we analyzed the parameter usability and usefulness of a mobile application for the iOS system, in addition to conducting its validation. Patients and Methods: The application was tested by 26 volunteers: 13 orthopedists and 13 orthopedic residents. Results: After applying the System Utility Score (SUS) questionnaire, which assesses the usability of an application, a score of 84.5 was obtained, a value that represents an A+ rating on the Sauro and Lewis scale. There was no statistically significant difference when comparing the SUS between the orthopedic residents and orthopedists. According to the usefulness perception analysis, 90% of the residents responded positively to the questions, while among orthopedists, the percentage was 75%, denoting a statistically significant difference (p = 0.002). Subsequently, the application underwent validation to assess whether the calculated angle measurements were reliable when compared with those obtained using the goniometer. No significant differences were observed when comparing the angles measured by the two evaluated methods. Conclusion/Clinical Relevance: In conclusion, the developed application can reliably contribute to the measurement of angles in radiographs, assisting in therapeutic decision-making, and may be used as an instrument to promote the teaching and learning processes in orthopedics.

An Evaluation of Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum Assessment Framework

Background: Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described. Introduction: Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device. Materials and Methods: Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests. Results: Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017). Discussion: Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit. Conclusions: Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

Point-of-Care Teleultrasound: A Systematic Review

Background: Telemedicine and point-of-care ultrasound have merged to create a field known as teleultrasound (TUS). Real-time TUS involves the transmission of bedside ultrasound (US) images with direct feedback from an US expert. In this review, we summarize the current uses of real-time TUS and discuss its potential future uses. Methods: We performed a literature search (PubMed and EMBase) to assess articles related to real-time TUS. Data were extracted using a standardized collection form, and relevant articles were separated into feasibility or clinical studies. Results: Our search yielded 45 articles, with most of the reports taking place in resource-constrained settings. A large portion of the studies discussed the use of the focused assessment with sonography in trauma exam. Others included musculoskeletal, vascular, and echocardiography. Conclusion: Real-time TUS allows for rapid access to diagnostic imaging in various clinical settings. This technology is poised to expand with many uses on the horizon.

Expanding Acute Stroke Care in Rural America: A Model for Statewide Success

Background: The state of West Virginia (WV) is often seen as a health care desert with a scarcity of hospitals and resources. The prevalence of cerebrovascular disease and associated comorbidities are also some of the highest in the nation. Introduction: Ischemic stroke is a time-sensitive diagnosis. Prompt treatment in WV is difficult due to limited and isolated stroke-ready hospitals. Adoption of telestroke has helped to bypass these obstacles and improve access to care. Materials and Methods: Retrospective analyses; using data from the American Heart Association's Get With The Guidelines Stroke Data Registry, and other statewide agencies, we looked for trends in the volume of patients treated with intravenous-tissue plasminogen activator (tPA) in WV. We also reviewed data from West Virginia University's (WVU) telestroke database to assess trends in consult volumes and quality metrics. Results: Since the establishment of WVU telestroke, the total number of stroke patients receiving tPA across the state increased by 173% from 2015 (259 patients) to 2018 (448 patients) (p < 0.0001). Telestroke consults made up 24% (107/448) of total statewide tPA administrations for 2018. Between 2016 and 2018, the total symptomatic hemorrhage rate for tPA treated patients through telestroke was 1% (3/292). Telestroke also facilitated local care by avoiding patient transfer on average 65% of the time. Conclusion: Not only has telestroke increased the quantity of treated acute ischemic strokes, but it has also done so safely and effectively even in resource-poor areas. These findings demonstrate that telestroke is a useful tool for treating strokes, particularly those that happen far from stroke centers.

m-Health for Burn Injury Consultations in a Low-Resource Setting: An Acceptability Study Among Health Care Providers

Introduction: The rapid adoption of smartphones, especially in low- and middle-income countries, has opened up novel ways to deliver health care, including diagnosis and management of burns. This study was conducted to measure acceptability and to identify factors that influence health care provider's attitudes toward m-health technology for emergency care of burn patients.

Methods: An extended version of the technology acceptance model (TAM) was used to assess the acceptability toward using m-health for burns. A questionnaire was distributed to health professionals at four hospitals in Dar Es Salaam, Tanzania. The questionnaire was based on several validated instruments and has previously been adopted for the sub-Saharan context. It measured constructs, including acceptability, usefulness, ease of use, social influences, and voluntariness. Univariate analysis was used to test our proposed hypotheses, and structural equation modeling was used to test the extended version of TAM.

Results: In our proposed test-model based on TAM, we found a significant relationship between compatibility—usefulness and usefulness—attitudes. The univariate analysis further revealed some differences between subgroups. Almost all health professionals in our sample already use smartphones for work purposes and were positive about using smartphones for burn consultations. Despite participants perceiving the application to be easy to use, they suggested that training and ongoing support should be available. Barriers mentioned include access to wireless internet and access to hospital-provided smartphones.

Functional Outcomes of Intravenous Thrombolysis in Octogenarians and Nonagenarians Through Telestroke: Single-Center Experience

Background: Patients aged ≥80 years are often underrepresented in stroke trials. Observational studies have shown that older patients have worse outcomes compared with younger patients, but outcomes in patients aged ≥80 years treated with intravenous (IV)-alteplase specifically through telestroke (TS) have not been studied. Aim: To compare clinical and safety outcomes in stroke patients aged ≥80 and 60-79 years treated with IV-alteplase via TS. Methods: The Medical University of South Carolina TS database was analyzed to identify IV-alteplase-treated patients aged 60-79 and ≥80 years between January 2015 and March 2018. Baseline demographics and TS-specific variables were compared. Clinical outcomes were assessed using the 90-day modified Rankin Scale (mRS). Safety outcomes were evaluated by comparing symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis was performed to determine odds ratio (OR) for good outcome (mRS 0-2) in the older age group at 90 days. Results: IV-alteplase was used in 151 patients in ≥80 years age group and 273 patients in 60-79 years age group. The older age group had more women and a higher National Institutes of Health Stroke Scale. The mean "ED-door-to-TS-consultant-login" time was shorter (21.6 min vs. 25.6 min; p = 0.048), but "TS-consultant-login-to-alteplase" time was longer (22.1 min vs. 19.3 min; p = 0.01) in the older age group. No difference was noted in eventual "door-to-needle" time. The older age group had fewer good outcomes (39.1% vs. 74%; p = 0.001) and more deaths (38% vs. 14%; p = 0.001) at 90 days. The sICH rates were similar in the two groups. The OR for good outcome in ≥80 years age group was 0.20 (95% CI: 0.12-0.34) after controlling for baseline variables. Conclusions: Stroke patients aged ≥80 years treated via TS have similar post-thrombolysis hemorrhage rates but worse clinical outcomes compared with patients aged 60-79 years.

ACCESS to Better Health and Clear Skies: Telemedicine and Greenhouse Gas Reduction

Introduction: This study estimates the reduction in greenhouse gas (GHG) emissions resulting from 2,020 neuro-emergent telemedicine consultations. We then estimate potential GHG reduction if the program was expanded nationwide. Materials and Methods: Travel distances in miles were calculated for each avoided patient transfer using hospital location data and ArcGIS^® tools. Potential GHG reductions from program expansion were calculated based on state and national stroke Diagnosis-Related Groups (DRGs). Along with average flight distance from a rural hospital to closest level one trauma center. Results: Participation in the Access to Critical Cerebral Emergent Support Services (ACCESS) from May 2015 to July 2017 resulted in 2,020 consultations. Of these consultations, there was a 70% (1,414) reduction in patient transfers. Emission reduction totaled 618,772 kg of carbon dioxide equivalents (CO₂e) (618.77 metric tons) or 0.306 metric tons of CO₂e per patient. Expanding the program across New Mexico and similar U.S. areas resulted in potential reductions of 4,307 (IQR 3,386-5,274) and 213,279 (IQR 169,320-263,570) metric tons of CO₂e. Conclusion: Transport accounts for 26% of global CO₂ emissions and is one of the few industrial sectors where emissions are still growing. What makes this study more impactful is that aviation's emissions are not part of the Kyoto Protocol and little is being done in this sector. GHG reduction was not the main intention of the ACCESS program, but it has shown to be a significant by-product.

A Hybrid Form of Telemedicine: A Unique Way to Extend Intensive Care Service to Neonates in Medically Underserved Areas

BACKGROUND

More than 90% of neonatal intensive care units (NICUs) in the United States are in urban areas, denying rural residents' easy NICU access. Telemedicine use for patient contact and management, although studied in adults and children, is understudied in neonates. A hybrid telemedicine system, with 24/7 neonatal nurse practitioner coverage and with a neonatologist physically present 3 days per week and telemedicine coverage the remaining days, was recently implemented at Comanche County Memorial Hospital's (CCMH) Level II NICU.

OBJECTIVE

To compare outcomes of moderately ill infants between 32-35 weeks gestational age (GA) managed by our hybrid telemedicine program with outcomes of similar neonates receiving standard care in a Level IV NICU at Oklahoma University Medical Center (OUMC).

DESIGN/METHODS

This was a retrospective, noninferiority study comparing outcomes of neonates receiving hybrid telemedicine versus standard care. All 32-35 weeks GA infants admitted between July 2013 and June 2015 were included. OUMC infants came from areas geographically comparable with CCMH. Infants requiring prolonged mechanical ventilation or advanced subspecialty services were excluded. Outcome variables were length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings.

RESULTS

Eighty-seven neonates at CCMH and 56 neonates at OUMC were included in the analysis. Compared with neonates at OUMC, neonates at CCMH had shorter hospitalizations, fewer days of supplemental oxygen, and fewer noninvasive ventilation support days, and reached full enteral feeds sooner.

CONCLUSIONS

The hybrid telemedicine system is a safe and effective strategy for extending intensive care to neonates in medically underserved areas.

Tele-Pediatric Intensive Care for Critically Ill Children in Syria

BACKGROUND

Armed conflicts can result in humanitarian crises and have major impacts on civilians, of whom children represent a significant proportion. Usual pediatric medical care is often disrupted and trauma resulting from war-related injuries is often devastating. High pediatric mortality rates are thus experienced in these ravaged medical environments.

INTRODUCTION

Using simple communication technology to provide real-time management recommendations from highly trained pediatric personnel can provide substantive clinical support and have a significant impact on pediatric morbidity and mortality.

MATERIALS AND METHODS

We implemented a "Tele-Pediatric Intensive Care" program (Tele-PICU) to provide real-time management consultation for critically ill and injured pediatric patients in Syria with intensive care needs.

RESULTS

Over the course of 7 months, 19 cases were evaluated, ranging in age from 1 day to 11 years. Consultation questions addressed a wide range of critical care needs. Five patients are known to have survived, three were transferred, five died, and six outcomes were unknown.

DISCUSSION

Based on this limited undertaking with its positive impact on survival, further development of Tele-PICU-based efforts with attention to implementation and barriers identified through this program is desirable.

CONCLUSION

Even limited Tele-PICU can provide timely and potentially lifesaving assistance to pediatric care providers. Future efforts are encouraged.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Virtual Visits for Upper Respiratory Tract Infections in Adults Associated with Positive Outcome in a Cox Model

There is no previous work on the relationship between a virtual visit for viral upper respiratory tract infection and improved outcome, even though there is data on the prevalence and other descriptors. We do not know if a virtual visit is an independent prognostic factor in community-based patients. With the exponential growth of this type of clinical visit, it is important for both clinical and planning considerations to evaluate this question. We analyzed a cohort of adult patients with newly diagnosed viral upper respiratory tract infection from a database of health plan patients seen virtually on telemedicine and in person at urgent cares in Las Vegas, Nevada between January 2014 and September 2014. Logistic regression, Kaplan-Meier survival analysis, and Cox proportional hazard model were used. Among the final 6,756 patients selected with upper respiratory tract infections (median age of 41.5), 6% had virtual visits, while the rest were seen in person at urgent cares. Patients who had virtual visits were more likely to be younger, but had no other firm demographic differences from those seen for upper respiratory tract infections in urgent care. Hazard ratio for 2-week follow-up (= failure), with no significant effect from covariates, was 0.55 (confidence interval 0.324-0.939, p < 0.05) in virtual patients. In this cohort of patients with upper respiratory tract infection, a virtual visit, compared to an in-person one at urgent care, is an independent prognostic factor for less follow-up within 2 weeks. Further research into other age groups, time periods, and different diagnoses using similar methodology is warranted.

Review of 5.5 Years' Experience Using E-mail-Based Telemedicine to Deliver Orthopedic Care to Remote Communities

INTRODUCTION

The use of e-mail-based telemedicine has been demonstrated as an effective and low-cost way of delivering healthcare to patients in remote areas who have limited access to medical services. We established a novel teleorthopedic service for a catchment area encompassing 972,000 km² using a commercial off-the-shelf e-mail application. Before the implementation of this program, patients with acute orthopedic injuries were required to travel by air up to 1,900 km for evaluation by an orthopedic surgeon. In the present study, we examined the patient demographics and consultation characteristics and calculated the cost savings associated with patient travel for this teleorthopedic service.

METHODS

We retrospectively reviewed 1,000 consecutive e-mail-based consults and radiographic images received for new patients with acute orthopedic injuries from January 2008 to June 2013. Seventy-nine consults were excluded due to incomplete documentation, leaving 921 available for analysis. The service records were examined to identify patient demographics, orthopedic diagnosis, the percentage of patients managed locally, and the medical indications for patients requiring transfer. As the travel costs for patients requiring transport to the university hospital center are borne by governmental health agencies, the savings accrued from treating patients in their home communities were also calculated.

RESULTS

For the 921 consultations, the mean age of patients was 27 years (range, 3 months-88 years), with 40.7% of all patients being younger than 18 years. The most common diagnoses were ankle fractures (15.2%), clavicle fractures (11.2%), distal radius fractures (11.2%), and fractures of the foot (10.2%). One hundred ninety patients (20.6%) required transfer, whereas 731 patients (79.4%) were treated in their home communities. Of the patients who were transferred, 123 (64.7%) required surgery, 55 (28.9%) required clinical evaluation by an orthopedic surgeon, and 12 (6.4%) required CT or MRI. Cost savings related to return trip travel expenses were calculated to be $5,538,120 Canadian (CAD) for the review period.

SUMMARY

Using an e-mail-based teleorthopedic service to manage acutely injured patients in remote communities allowed 79% of patients to be treated locally, with travel-related cost savings of $5,538,120 CAD.

Access and Quality of Care in Direct-to-Consumer Telemedicine

BACKGROUND

Direct-to-consumer (DTC) telemedicine serves millions of patients; however, there is limited research on the care provided. This study compared the quality of care at Teladoc ( www.teladoc.com ), a large DTC telemedicine company, with that at physician offices and compared access to care for Teladoc users and nonusers.

MATERIALS AND METHODS

Claims from all enrollees 18-64 years of age in the California Public Employees' Retirement System health maintenance organization between April 2012 and October 2013 were analyzed. We compared the performance of Teladoc and physician offices on applicable Healthcare Effectiveness Data and Information Set measures. Using geographic information system analyses, we compared Teladoc users and nonusers with respect to rural location and available primary care physicians.

RESULTS

Of enrollees offered Teladoc (n = 233,915), 3,043 adults had a total of 4,657 Teladoc visits. For the pharyngitis performance measure (ordering strep test), Teladoc performed worse than physician offices (3% versus 50%, p < 0.01). For the back pain measure (not ordering imaging), Teladoc and physician offices had similar performance (88% versus 79%, p = 0.20). For the bronchitis measure (not ordering antibiotics), Teladoc performed worse than physician offices (16.7 versus 27.9%, p < 0.01). In adjusted models, Teladoc users were not more likely to be located within a healthcare professional shortage area (odds ratio = 1.12, p = 0.10) or rural location (odds ratio = 1.0, p = 0.10).

CONCLUSIONS

Teladoc providers were less likely to order diagnostic testing and had poorer performance on appropriate antibiotic prescribing for bronchitis. Teladoc users were not preferentially located in underserved communities. Short-term needs include ongoing monitoring of quality and additional marketing and education to increase telemedicine use among underserved patients.

The Business Case for Tele-emergency

BACKGROUND

Tele-emergency is an expanding telehealth service that provides real-time audio/visual consultation delivered by an emergency medicine team to a remote, often rural, emergency department (ED). Financial analyses of tele-emergency in the literature are limited. This article expands the tele-emergency literature to describe the business case for tele-emergency. "Business case" is defined as a reasoned argument, supported by objective data and/or qualitative judgment, to implement or continue a service or product.

MATERIALS AND METHODS

To evaluate tele-emergency financing from the perspective of a critical access hospital (CAH), 10 financial analysis categories were defined. Telephone interviews, site visits, and financial data from the eEmergency program of Avera Health (Sioux Falls, SD) were used to populate the categories. Avera Health information was augmented with national data where available. Three financial scenarios were then analyzed for CAH profit/loss associated with tele-emergency.

RESULTS

Tele-emergency financial analysis demonstrated an $187,614 profit in a high revenue/low expense scenario, $49,841 profit in a midrange scenario, and $69,588 loss in a low revenue/high expense scenario.

CONCLUSIONS

Tele-emergency may be a profitable rural hospital service line if the participating hospital adjusts ED processes to take advantage of increased revenue/savings opportunities afforded by tele-emergency. Savings due to tele-emergency primarily accrue when physician ED backup and physician ED staffing costs are substituted.

Utilizing Telemedicine in the Trauma Intensive Care Unit: Does It Impact Teamwork?

BACKGROUND

The aim of this study was to examine the impact of a telemedical robot on trauma intensive care unit (TICU) clinician teamwork (i.e., team attitudes, behaviors, and cognitions) during patient rounds.

MATERIALS AND METHODS

Thirty-two healthcare providers who conduct rounds volunteered to take surveys assessing teamwork attitudes and cognitions at three time periods: (1) the onset of the study, (2) the end of the 30-day control period, and (3) the end of the 30-day experimental period, which immediately followed the control period. Rounds were recorded throughout the 30-day control period and 30-day experimental period to observe provider behaviors. For the initial 30 days, there was no access to telemedicine. For the final 30 days, the rounding healthcare providers had access to the RP-7 robot (Intouch Health Inc., Santa Barbara, CA), a telemedical tool that can facilitate patient rounds conducted away from bedside.

RESULTS

Using a one-tailed, one-way repeated-measures analysis of variance (ANOVA) to compare trust at Times 1, 2, and 3, there was no significant effect on trust: F(2, 14)=1.20, p=0.16. When a one-tailed, one-way repeated-measures ANOVA to compare transactive memory systems (TMS) at Times 1, 2, and 3 was conducted, there was no significant effect on TMS: F(2, 15)=1.33, p=0.15. We conducted a one-tailed, one-way repeated-measures ANOVA to compare team psychological safety at Times 1, 2, and 3, and there was no significant effect on team psychological safety: F(2,15)=1.53, p=0.12. There was a significant difference in communication between rounds with and without telemedicine [t(25)=-1.76, p<0.05], such that there was more task-based communication during telerounds. Telemedicine increased task-based communication and did not negatively impact team trust, psychological safety, or TMS during rounds.

CONCLUSIONS

Telemedicine may offer advantages for some teamwork competencies without sacrificing the efficacy of others and may be adopted by intact rounding teams without hindering teamwork.

Barriers and facilitators to pediatric emergency telemedicine in the United States

BACKGROUND

Pediatric emergency telemedicine has the potential to improve the quality of pediatric emergency care in underserved areas, reducing socioeconomic disparities in access to care. Yet, telemedicine in the pediatric emergency setting remains underutilized. We aimed to assess the current state of pediatric emergency telemedicine and identify unique success factors and barriers to widespread use.

MATERIALS AND METHODS

We conducted a telephone survey of current, former, and planned pediatric emergency telemedicine programs in the United States.

RESULTS

We surveyed 25 respondents at 20 unique sites, including 12 current, 5 planned, and 3 closed programs. Existing programs were located primarily in academic medical centers and served an average of 12.5 spoke sites (range, 1-30). Respondents identified five major barriers, including difficulties in cross-hospital credentialing, integration into established workflows, usability of technology, lack of physician buy-in, and misaligned incentives between patients and providers. Uneven reimbursement was also cited as a barrier, although this was not seen as major because most programs were able to operate independent of reimbursement, and many were not actively seeking reimbursement even when allowed. Critical success factors included selecting spoke hospitals based on receptivity rather than perceived need and cultivating clinical champions at local sites.

CONCLUSIONS

Although pediatric emergency telemedicine confronts many of the same challenges of other telemedicine applications, reimbursement is relatively less significant, and workflow disruption are relatively more significant in this setting. Although certain challenges such as credentialing can be addressed with available policy options, others such as the culture of transfer at rural emergency departments require innovative approaches.

Telestroke in an urban setting

BACKGROUND

Telestroke is a viable alternative in rural areas where neurologists or stroke expertise is unavailable. Urban applications of telestroke have not been previously described.

MATERIALS AND METHODS

All patients evaluated using remote telestroke technology at four urban spoke hospitals between March 2011 and March 2013 were included in this analysis. Telestroke services were provided by vascular fellowship-trained neurologists at one academic stroke center. Patient characteristics, time to initiation of consult, and treatment decisions were prospectively recorded. Stroke triage protocols and thrombolysis rates prior to initiation of telestroke were also obtained.

RESULTS

Four hundred ninety-eight patients were evaluated during the study period; mean age was 64.5 years, and 60.4% were female. Median time from initial emergency room call to start of teleconsult was 5 (range, 1-51) minutes. Average length of teleconsult was 30 minutes. Technical difficulties occurred in 80 (16.0%) teleconsults, but only 1 was major. Daytime calls (8 a.m.-5 p.m. Monday-Friday) accounted for 38.2% of teleconsults. Two hundred eighty-one patients (56.4%) were determined by teleconsult to have an acute ischemic stroke or transient ischemic attack (TIA). In 72 patients (14.5% overall; 25.6% of all ischemic stroke/TIA patients), intravenous alteplase (tissue plasminogen activator) was recommended. Transfer to the hub hospital occurred in 75 patients (15.1%).

CONCLUSIONS

Telestroke is a rapid and effective way to assess patients with suspected acute stroke in an urban setting. Its use may increase access to stroke neurologists and improve thrombolysis rates where competing responsibilities may delay, prevent, and even dissuade on-site evaluation by neurologists.