- Email: [email protected]
Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients
The American Journal of Surgery (2009) 198, 905–910
The Southwestern Surgical Congress
Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients Rifat Latifi, M.D.a,b,*, George J. Hadeed, M.P.H.a, Peter Rhee, M.D.a, Terrence O’Keeffe, M.D.a, Randall S. Friese, M.D.a, Julie L. Wynne, M.D.a, Michelle L. Ziemba, R.N.c, Dan Judkins, R.N.c a
Department of Surgery, Division of Trauma, Critical Care & Emergency Surgery, University of Arizona, Arizona Health Sciences Center, Tucson, AZ, USA; bArizona Telemedicine Program, University of Arizona College of Medicine, Tucson, AZ, USA; and cTrauma Services, University Medical Center, Tucson, AZ, USA KEYWORDS: Telemedicine; Teletrauma; Rural trauma; Telepresence
Abstract BACKGROUND: Teletrauma programs allow rural patients access to advanced trauma and emergency medical services that are often limited to urban areas. METHODS: A retrospective analysis of 59 teleconsults between 5 rural hospitals and a level I trauma center was performed. The objectives of this study were to report the initial experience with a telemedicine program connecting 5 rural hospitals with a level I trauma center. RESULTS: A total of 59 trauma and general surgery patients were evaluated. Of those, 35 (59%) were trauma patients, and 24 (41%) were general surgery patients. Fifty patients (85%) were from the first hospital at which teletrauma was established. For 6 patients, the teletrauma consults were considered potentially lifesaving; 17 patients (29%) were kept in the rural hospitals (8 trauma and 9 general surgery patients). Treating patients in the rural hospitals avoided transfers, saving an average of $19,698 per air transport or $2,055 per ground transport. CONCLUSIONS: The telepresence of a trauma surgeon aids in the initial evaluation, treatment, and care of patients, improving outcomes and reducing the costs of trauma care. © 2009 Published by Elsevier Inc.
Trauma is the leading cause of death in Arizonans aged 1 to 44 years old, accounting for 66% of all deaths reported in the state.1 Furthermore, of the 24,000 Arizonans who are severely injured each year, 40% do not reach designated trauma centers within the golden first hour.2– 4 There are an estimated 3,200 deaths each year in Arizona due to trauma, with a preventable mortality rate of 10%.4 In rural areas of the state, trauma access is limited; the nearest trauma center is often ⬎100 miles away. Although only 16.8% of all * Corresponding author. Tel.: 520-626-1988; fax: 520-626-5016. E-mail address: [email protected] Manuscript received March 6, 2009; revised manuscript August 17, 2009
0002-9610/$ - see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.amjsurg.2009.08.011
motor vehicle crashes occur in rural areas of Arizona, 53.7% of all traffic-related deaths statewide occur in rural areas.5 These grim statistics are similar to previously reported national data.6,7 Southern Arizona has a population of 1.5 million inhabitants. Since July 2003, the 290-bed University Medical Center (UMC) in Tucson has served as the only level I trauma center in the region. Given this lack of access to trauma care, the UMC trauma center and its faculty, in conjunction with the Arizona Telemedicine Program (ATP),8 initiated a creative teletrauma program to provide care and outreach in the region. The ATP is one of the most well regarded telemedicine programs in the world and serves most clinical disciplines through the application of telemedicine. The
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ATP has done ⬎900,000 consultations in ⬎60 clinical specialties. A teletrauma care program was the next logical step to address the lack of trauma and emergency care in the rural areas of southern Arizona. The successful use of telemedicine in other medical specialties has long been recognized; however, when applied to trauma and emergency care, the concept has been mostly unexplored. Only a few trauma centers have explored the possibilities of telemedicine for trauma care, but the emerging reports are encouraging, suggesting that telemedicine for trauma care may be a cost-effective and potentially lifesaving tool in the management of rural trauma.9 –12 In November 2004, the Southern Arizona Telemedicine and Telepresence (SATT) program was initiated, linking UMC in Tucson with the Southeast Medical Center in rural Douglas, a town 144 miles away with a population of 14,000. The objectives of the SATT program are to offer around-the-clock trauma and emergency management expertise through a telemedicine network. Offering this service 24 hours a day, 7 days a week, allowed the program to be available for consultation to all trauma or emergency surgical patients to small rural hospitals. The technical infrastructure of the teletrauma program was built on the ATP’s dedicated T1 network, allowing for the real-time transmission of video, audio, and vital signs on a secured, separate line that was monitored around the clock by the ATP’s technical personnel. Approximately 1.0 Mbps was needed to sustain such teleconsults, and up to 1.5 Mbps of total network bandwidth was available. The system allowed only 1 connection at a time, so multiple consultations could not be achieved at the same time on the same unit. We do have 2 different consultation locations in the event that we need to do simultaneous teleconsultations. Physiologic data are streamed from a monitor installed on the telemedicine unit, and monitoring devices at the referring hospital could be read using the video camera on the machine if needed. We selected Medvizer telemedicine equipment (VitelNet, McLean, VA). Medicolegal aspects of the pilot project were resolved, and all physicians who would be performing teleconsults obtained limited credentials at the Douglas hospital. Policies and procedures for providing teleconsults were established collaboratively by physicians, nurses, and technical staff. This included activation criteria for use of the system, obtaining legal consent, and steps to contact the trauma surgeon. We used the system for any trauma patient or emergency general surgery patient when we were able to provide such consultations or when the referring facility requested a teleconsultation. In the event that a patient was unable to consent, the case was treated as an emergency, and consent for care was implied. During our initial 13-month pilot project, we saw 21 patients. The telepresence of the trauma surgeon was considered a potentially lifesaving tool in the care, treatment, and evaluation of trauma and emergency surgical patients by both sides involved (that is, the UMC and the rural hospital).13 The success of our pilot project led to the
expansion of our program to an additional 4 rural Arizona hospitals—in Benson, Bisbee, Nogales, and Sierra Vista— through October 2008. In the last 2 months of 2008, we added 1 more rural hospital in Wilcox, a small town in southeastern Arizona. Approximately 55% of all trauma patients transferred to UMC in the past 3 years have come from rural hospitals. The average trauma volume of our teletrauma network was 126 trauma patients per year per site (range, 58 –219). The equipment ($275,000 for all regional teletrauma sites and the UMC command and control center) was funded by a grant from Blue Cross and Blue Shield of Arizona and the Universal Service Fund, a program designed to develop and advance the telecommunication infrastructure in rural areas. These grants covered the equipment and installation in each hospital at no cost to the hospital. Each hospital, however, was required to pay a $5,000 annual membership to ATP that provides technical assistance and access to educational programming and other clinical telemedicine specialties that ATP offers. Maintenance of the telemedicine units was provided free of charge for 1 year by the vendor and cost approximately $2,500 annually afterward for each site. The maintenance included replacement of all hardware and software components in the event of failure. There was no charge outside of the annual membership, maintenance, and Internet costs for the referring hospital, nor was there any charge to patients.
Methods We retrospectively reviewed the telemedicine records of all teleconsultations through the SATT program at the UMC in Tucson. The type of consult, mechanism of injury, change in management, transfer status, perceived impact on survival, and cost implications were collected from each consultation. Activation of the telemedicine system was performed for all trauma cases and emergency surgical patients at the discretion of the referring hospital and the availability of the trauma surgeon at the UMC to perform such consultation. We did not develop any exclusion criteria, because we wanted to encourage the sites to use the technology and make them comfortable with teleconsultations. Teleconsultations with the trauma surgeon were typically performed by physicians or health care providers such as nurse practitioners or physicians assistants. Both physicians and nurses from each hospital were trained to use the teletrauma system before the program went live in each site. Physicians and some of the nursing staff members at the rural hospitals were Advanced Trauma Life Support certified. The MedVizer unit is equipped with a fully controllable, full tilt, pan, and 12⫻ zoom camera that allows focusing closely on areas of interest or zooming out to get a wide shot of the trauma bay. There is capability to attach an additional camera to the machine, although none were used during this reporting period. Video and images could be recorded from
R. Latifi et al. Table 1
Telepresence and teletrauma
907
SATT program teleconsultations
Type of Consult
Number of Consults
Number of Transfers Prevented
Number of Patients Whose Treatment Changed Significantly
Number of Interventions Considered Potentially Lifesaving
Trauma Surgery Total
35 24 59
8 9 17
29 1 30
5 1 6
either the consult or referral site, but no information was used to evaluate the referring physician or nursing staff at the hospitals. The teleconsultation software is designed to be as hands free as possible. After connecting with the consultation site, the referring site does not have to physically be at the machine to use it, because video and voice are continuously transmitted without the need to press any buttons.
Results Over the initial 4-year span of the SATT program, 59 teleconsults were conducted between 5 rural hospitals in southern Arizona and the UMC. Of 59 patients evaluated, 50 (85%) came from the program’s first hospital (Douglas). Overall, 35 of the patients (59%) were treated for trauma
Table 2
Potentially lifesaving interventions through telemedicine
Patient
Reason for Consult
Admitting Diagnosis
Telemedicine Intervention
1
Motor vehicle collision ejection
Assistance with intubation, and identification of right main bronchus intubation on CR, resuscitation with blood transfusion and intravenous fluid, assistance with placement of femoral line, nasogastric decompression.
2
Necrotizing fasciitis
Closed head injury, scalp laceration, anemia secondary to acute blood loss, respiratory failure, left femur fracture, right tibia fracture, right metatarsal fracture, right second rib fracture Necrotizing fasciitis of right upper extremity
3
Fall from horse
Closed head injury, subdural hemorrhage—acute right temporal lobe, bilateral frontal contusions, basilar skull fracture
4
Gunshot wound
Gunshot wound to the left neck with transaction of jugular vein
5
Fall
Closed head injury with uncontrollable bleeding from temporal laceration
6
Assault
Closed head injury and severe agitation
CR ⫽ computed radiography; GCS ⫽ Glasgow Coma Scale score.
Discussed and convinced patient to be transferred to our hospital by explaining to her that she has a “flesh-eating bacterial infection,” after she had repeatedly refused hospitalization. She was brought in a state of septic shock and multiple organ failure requiring aggressive resuscitation and multiple surgical interventions. Her arm was able to be saved as a result. On telephone conversation patient’s GCS was reported to be 15. However, at teletrauma consultation, GCS was found to be 5, and referring doctor was advised to intubate the patient and transfer him at once via helicopter. Patient received morphine, and his mental status change was mistakenly considered the effect of morphine. At the referring hospital, the expanding hematoma of the neck and potential loss of airway was not recognized. Through telemedicine system, this was seen clearly, and doctor was advised to intubate the patient before he lost his airway. Patient on a combination of clopidogrel and aspirin who continued to bleed despite a large amount of pressure dressing. Identification of the bleeding point from the temporal artery was done through the teletrauma system, and the local physician was teleproctored in suturing and ligation of the artery successfully. Referring physician did not recognize that patient’s severe agitation was due to severe head injury, and wanted him to be transferred by helicopter in that state, despite the fact that there were 4 people trying to restrain him and keep him down. We advised the physician to intubate before helicopter ride.
908 Table 3 Arizona
The American Journal of Surgery, Vol 198, No 6, December 2009 Air and ground transfer costs from southern
Town
Average Cost of Helicopter Transport
Average Cost of Ground Transport
Benson Bisbee Nogales Douglas Sierra Vista Wilcox* Average of sites
$15,485 $20,936 $17,892 $25,494 $18,687 $19,430 $19,699
$1,689 $1,718 $2,412 $2,661 $1,797 $2,225 $2,247
*Wilcox was not factored into the average cost numbers for this study.
and 24 (41%) for general surgery. Of the 35 trauma patients, 32 (91%) suffered blunt injuries and 3 (9%) suffered penetrating injuries (Table 1). The most common injuries were, overwhelmingly, either orthopedic injuries or closed head injuries; several intra-abdominal and thoracic injuries also occurred. Of the 27 trauma patients transferred to the UMC, 8 (30%) underwent surgical intervention, and 19 (70%) received nonoperative care. The average transferred trauma injury severity score was 10 (range, 1– 41); the average patient age was 34.3 years (range, 1.5– 80 years). Of the 27 transferred trauma patients, 18 (67%) were discharged home directly from the trauma room. Of the 9 (33%) admitted for inpatient treatment, 6 were discharged to long-term care facilities. The average length of stay for transferred trauma patients was 5.5 days (range, 1–30). The telepresence of the trauma surgeon was considered potentially lifesaving when it was thought to have a profound impact on the patient that could not have been accomplished over the phone or without the ability to visualize the patient throughout the teleconsultation process. We identified 5 of the 35 trauma patients (14%) and 1 of the 24 general surgery patients (4%) (that patient had a necrotizing soft tissue infection) on whom we thought telemedicine had a significant impact (Table 2). Of the 59 patients seen through our SATT program, 17 (29%) remained at the local facilities: 8 (47%) were trauma patients and 9 (53%) were general surgery patients. Prevention of 17 unnecessary transfers saved an estimated $104,852 in transfer costs alone (saving an average of $19,698 per air transport or $2,055 per ground transport; Table 3). Overall, because of the telepresence of the trauma surgeon during the resuscitation phase, treatment changed for 29 of the 35 trauma patients (83%). The savings from the prevention of 1 unnecessary air transport was enough to pay for the entire cost of 1 system at the referring hospital, not including fixed costs such as Internet access, installation, and maintenance. The time from being notified of a patient to being telepresent was ⬍10 minutes. Most of these patients, while they are in the emergency rooms of rural hospitals, undergo minimal diagnostic efforts and brief resuscitation.
Comments Recent advances in technology coupled with the decreasing cost of equipment have opened the door for the adoption of telemedicine in trauma and emergency care. Robust systems can now be implemented that bring the telepresence of trauma surgeons or other emergency specialists into any rural hospital emergency room, allowing definitive trauma care to begin almost immediately after a patient’s arrival at a rural hospital. Trauma surgeons can now assist in the evaluation, resuscitation, and care of patients, a process that is often difficult to accomplish over the telephone alone. The ability to completely visualize a patient in real time is invaluable, enabling firsthand assessment by the surgeon as well as constant monitoring of the patient while the emergency team is at work. This telepresence can theoretically help prevent departures from the standard of care and avoid errors experienced in low-volume rural emergency centers, but there is still a need to study this more carefully in the future. Establishing a teletrauma program is a difficult process, but for injured and critically ill patients, it is worthwhile, because it can potentially reduce mortality, morbidity, and medical costs.10 –13 However, for such a program to become a sustainable part of the clinical fabric and of everyday practice, we recommend several steps to those planning similar programs14 (Table 4).
Table 4 Recommendations for a successful and sustainable telemedicine program for trauma and emergency management 1. Plan and develop a comprehensive business plan. 2. Identify a champion both at the trauma center and the local hospital. 3. Ensure acceptance of the rural hospital, including its emergency department or clinic, its physicians, its nursing staff, and its information technology staff. 4. Ensure proper administrative support at all sites. 5. Provide continuous education of new personnel at all sites through innovative online and classroom techniques. 6. Use an integrated approach involving engineers and technical personnel as well as nurses and physicians, all working very closely to resolve technical and other daily concerns. 7. Seek a private and community partnership to maintain the program’s sustainability through grants and other methods. 8. Create a partnership with an existing telemedicine program to ensure the security of patient data under HIPAA guidelines and regulations as well as providing technical support 24/7. 9. Allow for continuous reporting, disclosure, and full transparency. 10. Ensure a credentialing process at the referring hospitals for physicians. HIPAA ⫽ Health Insurance Portability and Accountability Act.
R. Latifi et al.
Telepresence and teletrauma
A teletrauma system has other benefits that are difficult to scientifically measure. Local physicians and nurses take comfort in knowing that they can have trauma surgeons or other experts “present” at a moment’s notice. The continuous hands-on education of physicians and nurses in providing trauma care during the evaluation and resuscitation of trauma patients through telemedicine programs is a substantive advantage. Ongoing education on the use of the teletrauma care system is extremely important. We found that the staff at both the UMC and the rural hospitals needed to be trained continuously, through interactive training sessions, online training modules, on-site training manuals, and a 24/7 help line. Despite these attempts at training the staff members, many still did not know how to use the system properly. We attribute this to two issues. First, the software’s design was not intuitive or easy to use, making education difficult for those users who were not computer savvy. Second, the low volume of teleconsults and continuous changes in medical staff at most of the rural hospitals did not allow for continuous, repetitive use, which would help facilitate an increased understanding of the system. One challenge that we immediately realized was that the use of our teletrauma system was confined to small area in the trauma bay. For a patient on the other side of the trauma bay, or in another part of the rural hospital, it was almost impossible to use the system. Although the teletrauma system is mobile (it can be moved from room to room), the system would benefit from being connected to a wireless IEEE 802.11n network, which would allow its deployment throughout the hospital and would support the large amount of bandwidth used during a teleconsult. Additionally, the use of multiple cameras could have an increased benefit to the system, allowing trauma surgeons to simultaneously monitor narrow camera views and larger views of the trauma bay. Our system had a mounted camera that was approximately 7 feet in the air to allow for an unobstructed view of the trauma bay. Having multiple video feeds would allow for the trauma surgeon to have a complete picture as to what exactly is going on in the trauma bay. The user interface of our teletrauma system was also problematic. The nurses and physicians found it intimidating to use, often avoiding it because of its perceived complexity. In response, we developed a two-step training program that introduced the basic use of the system as well as its advanced features. Training was (and is) available anytime at the request of the rural hospital. We found that including the information technology department at each hospital significantly helped with troubleshooting and provided basic assistance.
Conclusions The teletrauma program in southern Arizona has become an integral part of our state’s expert trauma care capacity. In addition to providing state-of-the-art care to trauma patients at a moment’s notice, the cost savings to the medical
909 system are potentially significant, facilitating the program’s acceptance by the participating hospitals, caregivers, and insurance companies. Most important, the quality of trauma patient care has been considerably enhanced.
References 1. Arizona Department of Health Services. Leading causes of death in Arizona, ages 1– 44, 1999 –2002. Atlanta, GA: National Center for Injury Prevention and Control. 2. Arizona Executive Order 2008 –26. 3. Murdock D. Trauma: when there’s no time to count. AORN J 2008; 87:322– 8. 4. American College of Surgeons. Trauma system consultation: state of Arizona. Available at: http://www.azdhs.gov/bems/trauma-pdf/Arizona TSC Report_Final.pdf. Accessed January 14, 2009. 5. Arizona Department of Transportation Motor Vehicle Division. 2007 motor vehicle crash facts for the state of Arizona. Available at: http:// www.azdot.gov/mvd/statistics/crash/PDF/07crashfacts.pdf. Accessed January 14, 2009. 6. Trunkey DD. Trauma centers and trauma systems. JAMA 2003;289: 12:1566 –7. 7. Congressional Office of Technology Assessment. Rural emergency medical services (Publication OTA-H-445). Washington, DC: US Government Printing Office; 1989. 8. Arizona Telemedicine Program. Home page. Available at: http://www. telemedicine.arizona.edu. Accessed March 15, 2009. 9. Latifi R, Ong CA, Peck KA, et al. Telepresence and telemedicine in trauma and emergency care management. Eur Surg 2005;5:293–7. 10. Rogers FB, Ricci M, Caputo M, et al. The use of telemedicine for real-time video consultation between trauma center and community hospital in a rural setting improves early trauma care: preliminary results. J Trauma 2001;51:1037– 41. 11. Duchense JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma 2008;64:92– 8. 12. Aucar J, Granchi T, Liscum K, et al. Is regionalization of trauma care using telemedicine feasible and desirable? Am J Surg 2000;180:535–9. 13. Latifi R, Weinstein RS, Porter JM, et al. Telemedicine and telepresence for trauma and emergency care management. Scand J Surg 2007;96:281–9. 14. Latifi R. The do’s and don’ts when you establish telemedicine and e-health (not only) in developing countries. Stud Health Technol Inform 2008;39 – 44.
Discussion John Aucar, M.D. (Urbana, IL): I wish to congratulate the authors on their progressive and forward thinking approach to trauma and general surgical care. However, they provide a paucity of qualitative or quantitative data to support their claims that these techniques can reduce overall cost, prevent unnecessary transfers, improve quality of care, or save lives. The manuscript even omits citation of either the methodology or results and one of the few articles described quantitative approach to assessing performance of remote evaluation of trauma patients which was presented before this Congress and published several years ago by yours truly. That article emphasizes that we should be focused on techniques rather than technology. Our increasing
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attraction to the use of advanced technologies such as telemedicine, electronic records, and remote control surgery always reminds me of an old saying: if you meet a talking dog, it shouldn’t much matter what it says, it is just the fact that it talks at all. But after a while we get over the shock and need to start listening a little closer to see if the dog is making sense or talking gibberish. I have 3 questions: Did you maintain systematic data on the time course of consultations and transfers to see whether this actually speeds up or slows down the process of care? Two, you described an average of low acuity population; transfers were avoided in 8 trauma patients, and 18 of the 27 transferred patients were discharged from your emergency department. Can you offer any insight into the clinical characteristics or decision points that distinguishes the prevented transfers from those that were actually sent? Were any of those other transfers considered potentially preventable? Three, there was a case where a local surgeon was encouraged to perform splenectomy and stabilize the patient before transfer. We can see how that would be considered a lifesaving maneuver. In the 5 other cases, how did you determine that there was lifesaving interventions and how can we distinguish those from the alternative which might be considered life threatening? Rifat Latifi, M.D. (Tucson, AZ): Your first question, does telemedicine delay the transfer or not or perhaps speed up the process? We actually did not study that question. Initially, we were just trying to convince the doctors and administration of hospitals in the region that this is a good thing to have—just like saying a toast in the morning is good for you. On question 2, is really an important one. We believe that 18 of 27 patients that were discharged to home from our trauma center could have been managed in the hospitals that came from. The main reason for these transfers of these patients is the comfort of health care provider on the other side. We all had gotten those phone calls “I don’t really feel comfortable; can I send it to you?” This comfort however is getting better, we think due to telemedicine. The third question is a complex one. I am well aware that the case that was done by Vermont group, and I agree that was a lifesaving procedure done by the local surgeon. On the other hand, although simple, defining “lifesaving” is not an easy task. Our first patient managed by telemedicine would have died—no question about if we were not there to help resuscitate her for 45 minutes. The injured gentleman who was in coma, he was about to be sent to us by car on 2 hours trip unintubated. We recognized the severity of the
injury and transferred to our hospital by helicopter where he was operated 45 minutes later. The lady with the necrotizing fasciitis, she was refusing to come to the hospital. By talking to the patient herself over the video, we were able to convince her that she needs higher level of care. When she arrived in our hospital she was in full septic shock. Steve Smith, M.D. (Roanoke, VA): I have spent the last 15 years of my career working in trauma centers that were surrounded by relatively small hospitals working under very austere circumstances so I can understand your passion. I have two questions for you. What about training of the outlying facilities? Have you taken the rural trauma team development course out to these facilities? Dave Kappel from West Virginia presented a paper recently at another meeting that showed that something as simple as introduction to the rural trauma team development course accomplished much of the same thing that you’ve talked about and I think quite honestly that would be less expensive as far as facilitating appropriate and timely transfer of patients. Secondly, I think that a couple of the obstacles that have interfered with the progression of this type of practice are continued fears or concerns about no reimbursement for the trauma center and increased liability for the trauma surgeons who are providing this on site guidance or consultation. Has any progress been made in this area? Dr. Latifi: Let me take the last question first because I think it is really crucial to address the issue of fear of liability. I believe that small hospitals will have less malpractice if they have you as the trauma expert seeing the patients and helping the resuscitation. Obviously, you dictate the note, and take responsibility for your advice and work closely with referring physician. So I think the use of telemedicine for trauma and emergency surgery will lower malpractice rate, although I have no data to support that yet. I have never heard of a case of telemedicine malpractice from trauma and I have been doing this now for a few years. We actually dictate a note and charge for this telemedicine consultation; it is very small, but nonetheless it is probably comparable with if they had come to our hospital. On training—we actually have done two types of training. Number one, we train all the doctors on telemedicine equipment and how to use it, but on the trauma issues as well. The conversation is between us trauma surgeons and a rural physician is changing. The rural providers are becoming more sophisticated, I believe due to our routine telemedicine consultations.
The Southwestern Surgical Congress
Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients Rifat Latifi, M.D.a,b,*, George J. Hadeed, M.P.H.a, Peter Rhee, M.D.a, Terrence O’Keeffe, M.D.a, Randall S. Friese, M.D.a, Julie L. Wynne, M.D.a, Michelle L. Ziemba, R.N.c, Dan Judkins, R.N.c a
Department of Surgery, Division of Trauma, Critical Care & Emergency Surgery, University of Arizona, Arizona Health Sciences Center, Tucson, AZ, USA; bArizona Telemedicine Program, University of Arizona College of Medicine, Tucson, AZ, USA; and cTrauma Services, University Medical Center, Tucson, AZ, USA KEYWORDS: Telemedicine; Teletrauma; Rural trauma; Telepresence
Abstract BACKGROUND: Teletrauma programs allow rural patients access to advanced trauma and emergency medical services that are often limited to urban areas. METHODS: A retrospective analysis of 59 teleconsults between 5 rural hospitals and a level I trauma center was performed. The objectives of this study were to report the initial experience with a telemedicine program connecting 5 rural hospitals with a level I trauma center. RESULTS: A total of 59 trauma and general surgery patients were evaluated. Of those, 35 (59%) were trauma patients, and 24 (41%) were general surgery patients. Fifty patients (85%) were from the first hospital at which teletrauma was established. For 6 patients, the teletrauma consults were considered potentially lifesaving; 17 patients (29%) were kept in the rural hospitals (8 trauma and 9 general surgery patients). Treating patients in the rural hospitals avoided transfers, saving an average of $19,698 per air transport or $2,055 per ground transport. CONCLUSIONS: The telepresence of a trauma surgeon aids in the initial evaluation, treatment, and care of patients, improving outcomes and reducing the costs of trauma care. © 2009 Published by Elsevier Inc.
Trauma is the leading cause of death in Arizonans aged 1 to 44 years old, accounting for 66% of all deaths reported in the state.1 Furthermore, of the 24,000 Arizonans who are severely injured each year, 40% do not reach designated trauma centers within the golden first hour.2– 4 There are an estimated 3,200 deaths each year in Arizona due to trauma, with a preventable mortality rate of 10%.4 In rural areas of the state, trauma access is limited; the nearest trauma center is often ⬎100 miles away. Although only 16.8% of all * Corresponding author. Tel.: 520-626-1988; fax: 520-626-5016. E-mail address: [email protected] Manuscript received March 6, 2009; revised manuscript August 17, 2009
0002-9610/$ - see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.amjsurg.2009.08.011
motor vehicle crashes occur in rural areas of Arizona, 53.7% of all traffic-related deaths statewide occur in rural areas.5 These grim statistics are similar to previously reported national data.6,7 Southern Arizona has a population of 1.5 million inhabitants. Since July 2003, the 290-bed University Medical Center (UMC) in Tucson has served as the only level I trauma center in the region. Given this lack of access to trauma care, the UMC trauma center and its faculty, in conjunction with the Arizona Telemedicine Program (ATP),8 initiated a creative teletrauma program to provide care and outreach in the region. The ATP is one of the most well regarded telemedicine programs in the world and serves most clinical disciplines through the application of telemedicine. The
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ATP has done ⬎900,000 consultations in ⬎60 clinical specialties. A teletrauma care program was the next logical step to address the lack of trauma and emergency care in the rural areas of southern Arizona. The successful use of telemedicine in other medical specialties has long been recognized; however, when applied to trauma and emergency care, the concept has been mostly unexplored. Only a few trauma centers have explored the possibilities of telemedicine for trauma care, but the emerging reports are encouraging, suggesting that telemedicine for trauma care may be a cost-effective and potentially lifesaving tool in the management of rural trauma.9 –12 In November 2004, the Southern Arizona Telemedicine and Telepresence (SATT) program was initiated, linking UMC in Tucson with the Southeast Medical Center in rural Douglas, a town 144 miles away with a population of 14,000. The objectives of the SATT program are to offer around-the-clock trauma and emergency management expertise through a telemedicine network. Offering this service 24 hours a day, 7 days a week, allowed the program to be available for consultation to all trauma or emergency surgical patients to small rural hospitals. The technical infrastructure of the teletrauma program was built on the ATP’s dedicated T1 network, allowing for the real-time transmission of video, audio, and vital signs on a secured, separate line that was monitored around the clock by the ATP’s technical personnel. Approximately 1.0 Mbps was needed to sustain such teleconsults, and up to 1.5 Mbps of total network bandwidth was available. The system allowed only 1 connection at a time, so multiple consultations could not be achieved at the same time on the same unit. We do have 2 different consultation locations in the event that we need to do simultaneous teleconsultations. Physiologic data are streamed from a monitor installed on the telemedicine unit, and monitoring devices at the referring hospital could be read using the video camera on the machine if needed. We selected Medvizer telemedicine equipment (VitelNet, McLean, VA). Medicolegal aspects of the pilot project were resolved, and all physicians who would be performing teleconsults obtained limited credentials at the Douglas hospital. Policies and procedures for providing teleconsults were established collaboratively by physicians, nurses, and technical staff. This included activation criteria for use of the system, obtaining legal consent, and steps to contact the trauma surgeon. We used the system for any trauma patient or emergency general surgery patient when we were able to provide such consultations or when the referring facility requested a teleconsultation. In the event that a patient was unable to consent, the case was treated as an emergency, and consent for care was implied. During our initial 13-month pilot project, we saw 21 patients. The telepresence of the trauma surgeon was considered a potentially lifesaving tool in the care, treatment, and evaluation of trauma and emergency surgical patients by both sides involved (that is, the UMC and the rural hospital).13 The success of our pilot project led to the
expansion of our program to an additional 4 rural Arizona hospitals—in Benson, Bisbee, Nogales, and Sierra Vista— through October 2008. In the last 2 months of 2008, we added 1 more rural hospital in Wilcox, a small town in southeastern Arizona. Approximately 55% of all trauma patients transferred to UMC in the past 3 years have come from rural hospitals. The average trauma volume of our teletrauma network was 126 trauma patients per year per site (range, 58 –219). The equipment ($275,000 for all regional teletrauma sites and the UMC command and control center) was funded by a grant from Blue Cross and Blue Shield of Arizona and the Universal Service Fund, a program designed to develop and advance the telecommunication infrastructure in rural areas. These grants covered the equipment and installation in each hospital at no cost to the hospital. Each hospital, however, was required to pay a $5,000 annual membership to ATP that provides technical assistance and access to educational programming and other clinical telemedicine specialties that ATP offers. Maintenance of the telemedicine units was provided free of charge for 1 year by the vendor and cost approximately $2,500 annually afterward for each site. The maintenance included replacement of all hardware and software components in the event of failure. There was no charge outside of the annual membership, maintenance, and Internet costs for the referring hospital, nor was there any charge to patients.
Methods We retrospectively reviewed the telemedicine records of all teleconsultations through the SATT program at the UMC in Tucson. The type of consult, mechanism of injury, change in management, transfer status, perceived impact on survival, and cost implications were collected from each consultation. Activation of the telemedicine system was performed for all trauma cases and emergency surgical patients at the discretion of the referring hospital and the availability of the trauma surgeon at the UMC to perform such consultation. We did not develop any exclusion criteria, because we wanted to encourage the sites to use the technology and make them comfortable with teleconsultations. Teleconsultations with the trauma surgeon were typically performed by physicians or health care providers such as nurse practitioners or physicians assistants. Both physicians and nurses from each hospital were trained to use the teletrauma system before the program went live in each site. Physicians and some of the nursing staff members at the rural hospitals were Advanced Trauma Life Support certified. The MedVizer unit is equipped with a fully controllable, full tilt, pan, and 12⫻ zoom camera that allows focusing closely on areas of interest or zooming out to get a wide shot of the trauma bay. There is capability to attach an additional camera to the machine, although none were used during this reporting period. Video and images could be recorded from
R. Latifi et al. Table 1
Telepresence and teletrauma
907
SATT program teleconsultations
Type of Consult
Number of Consults
Number of Transfers Prevented
Number of Patients Whose Treatment Changed Significantly
Number of Interventions Considered Potentially Lifesaving
Trauma Surgery Total
35 24 59
8 9 17
29 1 30
5 1 6
either the consult or referral site, but no information was used to evaluate the referring physician or nursing staff at the hospitals. The teleconsultation software is designed to be as hands free as possible. After connecting with the consultation site, the referring site does not have to physically be at the machine to use it, because video and voice are continuously transmitted without the need to press any buttons.
Results Over the initial 4-year span of the SATT program, 59 teleconsults were conducted between 5 rural hospitals in southern Arizona and the UMC. Of 59 patients evaluated, 50 (85%) came from the program’s first hospital (Douglas). Overall, 35 of the patients (59%) were treated for trauma
Table 2
Potentially lifesaving interventions through telemedicine
Patient
Reason for Consult
Admitting Diagnosis
Telemedicine Intervention
1
Motor vehicle collision ejection
Assistance with intubation, and identification of right main bronchus intubation on CR, resuscitation with blood transfusion and intravenous fluid, assistance with placement of femoral line, nasogastric decompression.
2
Necrotizing fasciitis
Closed head injury, scalp laceration, anemia secondary to acute blood loss, respiratory failure, left femur fracture, right tibia fracture, right metatarsal fracture, right second rib fracture Necrotizing fasciitis of right upper extremity
3
Fall from horse
Closed head injury, subdural hemorrhage—acute right temporal lobe, bilateral frontal contusions, basilar skull fracture
4
Gunshot wound
Gunshot wound to the left neck with transaction of jugular vein
5
Fall
Closed head injury with uncontrollable bleeding from temporal laceration
6
Assault
Closed head injury and severe agitation
CR ⫽ computed radiography; GCS ⫽ Glasgow Coma Scale score.
Discussed and convinced patient to be transferred to our hospital by explaining to her that she has a “flesh-eating bacterial infection,” after she had repeatedly refused hospitalization. She was brought in a state of septic shock and multiple organ failure requiring aggressive resuscitation and multiple surgical interventions. Her arm was able to be saved as a result. On telephone conversation patient’s GCS was reported to be 15. However, at teletrauma consultation, GCS was found to be 5, and referring doctor was advised to intubate the patient and transfer him at once via helicopter. Patient received morphine, and his mental status change was mistakenly considered the effect of morphine. At the referring hospital, the expanding hematoma of the neck and potential loss of airway was not recognized. Through telemedicine system, this was seen clearly, and doctor was advised to intubate the patient before he lost his airway. Patient on a combination of clopidogrel and aspirin who continued to bleed despite a large amount of pressure dressing. Identification of the bleeding point from the temporal artery was done through the teletrauma system, and the local physician was teleproctored in suturing and ligation of the artery successfully. Referring physician did not recognize that patient’s severe agitation was due to severe head injury, and wanted him to be transferred by helicopter in that state, despite the fact that there were 4 people trying to restrain him and keep him down. We advised the physician to intubate before helicopter ride.
908 Table 3 Arizona
The American Journal of Surgery, Vol 198, No 6, December 2009 Air and ground transfer costs from southern
Town
Average Cost of Helicopter Transport
Average Cost of Ground Transport
Benson Bisbee Nogales Douglas Sierra Vista Wilcox* Average of sites
$15,485 $20,936 $17,892 $25,494 $18,687 $19,430 $19,699
$1,689 $1,718 $2,412 $2,661 $1,797 $2,225 $2,247
*Wilcox was not factored into the average cost numbers for this study.
and 24 (41%) for general surgery. Of the 35 trauma patients, 32 (91%) suffered blunt injuries and 3 (9%) suffered penetrating injuries (Table 1). The most common injuries were, overwhelmingly, either orthopedic injuries or closed head injuries; several intra-abdominal and thoracic injuries also occurred. Of the 27 trauma patients transferred to the UMC, 8 (30%) underwent surgical intervention, and 19 (70%) received nonoperative care. The average transferred trauma injury severity score was 10 (range, 1– 41); the average patient age was 34.3 years (range, 1.5– 80 years). Of the 27 transferred trauma patients, 18 (67%) were discharged home directly from the trauma room. Of the 9 (33%) admitted for inpatient treatment, 6 were discharged to long-term care facilities. The average length of stay for transferred trauma patients was 5.5 days (range, 1–30). The telepresence of the trauma surgeon was considered potentially lifesaving when it was thought to have a profound impact on the patient that could not have been accomplished over the phone or without the ability to visualize the patient throughout the teleconsultation process. We identified 5 of the 35 trauma patients (14%) and 1 of the 24 general surgery patients (4%) (that patient had a necrotizing soft tissue infection) on whom we thought telemedicine had a significant impact (Table 2). Of the 59 patients seen through our SATT program, 17 (29%) remained at the local facilities: 8 (47%) were trauma patients and 9 (53%) were general surgery patients. Prevention of 17 unnecessary transfers saved an estimated $104,852 in transfer costs alone (saving an average of $19,698 per air transport or $2,055 per ground transport; Table 3). Overall, because of the telepresence of the trauma surgeon during the resuscitation phase, treatment changed for 29 of the 35 trauma patients (83%). The savings from the prevention of 1 unnecessary air transport was enough to pay for the entire cost of 1 system at the referring hospital, not including fixed costs such as Internet access, installation, and maintenance. The time from being notified of a patient to being telepresent was ⬍10 minutes. Most of these patients, while they are in the emergency rooms of rural hospitals, undergo minimal diagnostic efforts and brief resuscitation.
Comments Recent advances in technology coupled with the decreasing cost of equipment have opened the door for the adoption of telemedicine in trauma and emergency care. Robust systems can now be implemented that bring the telepresence of trauma surgeons or other emergency specialists into any rural hospital emergency room, allowing definitive trauma care to begin almost immediately after a patient’s arrival at a rural hospital. Trauma surgeons can now assist in the evaluation, resuscitation, and care of patients, a process that is often difficult to accomplish over the telephone alone. The ability to completely visualize a patient in real time is invaluable, enabling firsthand assessment by the surgeon as well as constant monitoring of the patient while the emergency team is at work. This telepresence can theoretically help prevent departures from the standard of care and avoid errors experienced in low-volume rural emergency centers, but there is still a need to study this more carefully in the future. Establishing a teletrauma program is a difficult process, but for injured and critically ill patients, it is worthwhile, because it can potentially reduce mortality, morbidity, and medical costs.10 –13 However, for such a program to become a sustainable part of the clinical fabric and of everyday practice, we recommend several steps to those planning similar programs14 (Table 4).
Table 4 Recommendations for a successful and sustainable telemedicine program for trauma and emergency management 1. Plan and develop a comprehensive business plan. 2. Identify a champion both at the trauma center and the local hospital. 3. Ensure acceptance of the rural hospital, including its emergency department or clinic, its physicians, its nursing staff, and its information technology staff. 4. Ensure proper administrative support at all sites. 5. Provide continuous education of new personnel at all sites through innovative online and classroom techniques. 6. Use an integrated approach involving engineers and technical personnel as well as nurses and physicians, all working very closely to resolve technical and other daily concerns. 7. Seek a private and community partnership to maintain the program’s sustainability through grants and other methods. 8. Create a partnership with an existing telemedicine program to ensure the security of patient data under HIPAA guidelines and regulations as well as providing technical support 24/7. 9. Allow for continuous reporting, disclosure, and full transparency. 10. Ensure a credentialing process at the referring hospitals for physicians. HIPAA ⫽ Health Insurance Portability and Accountability Act.
R. Latifi et al.
Telepresence and teletrauma
A teletrauma system has other benefits that are difficult to scientifically measure. Local physicians and nurses take comfort in knowing that they can have trauma surgeons or other experts “present” at a moment’s notice. The continuous hands-on education of physicians and nurses in providing trauma care during the evaluation and resuscitation of trauma patients through telemedicine programs is a substantive advantage. Ongoing education on the use of the teletrauma care system is extremely important. We found that the staff at both the UMC and the rural hospitals needed to be trained continuously, through interactive training sessions, online training modules, on-site training manuals, and a 24/7 help line. Despite these attempts at training the staff members, many still did not know how to use the system properly. We attribute this to two issues. First, the software’s design was not intuitive or easy to use, making education difficult for those users who were not computer savvy. Second, the low volume of teleconsults and continuous changes in medical staff at most of the rural hospitals did not allow for continuous, repetitive use, which would help facilitate an increased understanding of the system. One challenge that we immediately realized was that the use of our teletrauma system was confined to small area in the trauma bay. For a patient on the other side of the trauma bay, or in another part of the rural hospital, it was almost impossible to use the system. Although the teletrauma system is mobile (it can be moved from room to room), the system would benefit from being connected to a wireless IEEE 802.11n network, which would allow its deployment throughout the hospital and would support the large amount of bandwidth used during a teleconsult. Additionally, the use of multiple cameras could have an increased benefit to the system, allowing trauma surgeons to simultaneously monitor narrow camera views and larger views of the trauma bay. Our system had a mounted camera that was approximately 7 feet in the air to allow for an unobstructed view of the trauma bay. Having multiple video feeds would allow for the trauma surgeon to have a complete picture as to what exactly is going on in the trauma bay. The user interface of our teletrauma system was also problematic. The nurses and physicians found it intimidating to use, often avoiding it because of its perceived complexity. In response, we developed a two-step training program that introduced the basic use of the system as well as its advanced features. Training was (and is) available anytime at the request of the rural hospital. We found that including the information technology department at each hospital significantly helped with troubleshooting and provided basic assistance.
Conclusions The teletrauma program in southern Arizona has become an integral part of our state’s expert trauma care capacity. In addition to providing state-of-the-art care to trauma patients at a moment’s notice, the cost savings to the medical
909 system are potentially significant, facilitating the program’s acceptance by the participating hospitals, caregivers, and insurance companies. Most important, the quality of trauma patient care has been considerably enhanced.
References 1. Arizona Department of Health Services. Leading causes of death in Arizona, ages 1– 44, 1999 –2002. Atlanta, GA: National Center for Injury Prevention and Control. 2. Arizona Executive Order 2008 –26. 3. Murdock D. Trauma: when there’s no time to count. AORN J 2008; 87:322– 8. 4. American College of Surgeons. Trauma system consultation: state of Arizona. Available at: http://www.azdhs.gov/bems/trauma-pdf/Arizona TSC Report_Final.pdf. Accessed January 14, 2009. 5. Arizona Department of Transportation Motor Vehicle Division. 2007 motor vehicle crash facts for the state of Arizona. Available at: http:// www.azdot.gov/mvd/statistics/crash/PDF/07crashfacts.pdf. Accessed January 14, 2009. 6. Trunkey DD. Trauma centers and trauma systems. JAMA 2003;289: 12:1566 –7. 7. Congressional Office of Technology Assessment. Rural emergency medical services (Publication OTA-H-445). Washington, DC: US Government Printing Office; 1989. 8. Arizona Telemedicine Program. Home page. Available at: http://www. telemedicine.arizona.edu. Accessed March 15, 2009. 9. Latifi R, Ong CA, Peck KA, et al. Telepresence and telemedicine in trauma and emergency care management. Eur Surg 2005;5:293–7. 10. Rogers FB, Ricci M, Caputo M, et al. The use of telemedicine for real-time video consultation between trauma center and community hospital in a rural setting improves early trauma care: preliminary results. J Trauma 2001;51:1037– 41. 11. Duchense JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma 2008;64:92– 8. 12. Aucar J, Granchi T, Liscum K, et al. Is regionalization of trauma care using telemedicine feasible and desirable? Am J Surg 2000;180:535–9. 13. Latifi R, Weinstein RS, Porter JM, et al. Telemedicine and telepresence for trauma and emergency care management. Scand J Surg 2007;96:281–9. 14. Latifi R. The do’s and don’ts when you establish telemedicine and e-health (not only) in developing countries. Stud Health Technol Inform 2008;39 – 44.
Discussion John Aucar, M.D. (Urbana, IL): I wish to congratulate the authors on their progressive and forward thinking approach to trauma and general surgical care. However, they provide a paucity of qualitative or quantitative data to support their claims that these techniques can reduce overall cost, prevent unnecessary transfers, improve quality of care, or save lives. The manuscript even omits citation of either the methodology or results and one of the few articles described quantitative approach to assessing performance of remote evaluation of trauma patients which was presented before this Congress and published several years ago by yours truly. That article emphasizes that we should be focused on techniques rather than technology. Our increasing
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attraction to the use of advanced technologies such as telemedicine, electronic records, and remote control surgery always reminds me of an old saying: if you meet a talking dog, it shouldn’t much matter what it says, it is just the fact that it talks at all. But after a while we get over the shock and need to start listening a little closer to see if the dog is making sense or talking gibberish. I have 3 questions: Did you maintain systematic data on the time course of consultations and transfers to see whether this actually speeds up or slows down the process of care? Two, you described an average of low acuity population; transfers were avoided in 8 trauma patients, and 18 of the 27 transferred patients were discharged from your emergency department. Can you offer any insight into the clinical characteristics or decision points that distinguishes the prevented transfers from those that were actually sent? Were any of those other transfers considered potentially preventable? Three, there was a case where a local surgeon was encouraged to perform splenectomy and stabilize the patient before transfer. We can see how that would be considered a lifesaving maneuver. In the 5 other cases, how did you determine that there was lifesaving interventions and how can we distinguish those from the alternative which might be considered life threatening? Rifat Latifi, M.D. (Tucson, AZ): Your first question, does telemedicine delay the transfer or not or perhaps speed up the process? We actually did not study that question. Initially, we were just trying to convince the doctors and administration of hospitals in the region that this is a good thing to have—just like saying a toast in the morning is good for you. On question 2, is really an important one. We believe that 18 of 27 patients that were discharged to home from our trauma center could have been managed in the hospitals that came from. The main reason for these transfers of these patients is the comfort of health care provider on the other side. We all had gotten those phone calls “I don’t really feel comfortable; can I send it to you?” This comfort however is getting better, we think due to telemedicine. The third question is a complex one. I am well aware that the case that was done by Vermont group, and I agree that was a lifesaving procedure done by the local surgeon. On the other hand, although simple, defining “lifesaving” is not an easy task. Our first patient managed by telemedicine would have died—no question about if we were not there to help resuscitate her for 45 minutes. The injured gentleman who was in coma, he was about to be sent to us by car on 2 hours trip unintubated. We recognized the severity of the
injury and transferred to our hospital by helicopter where he was operated 45 minutes later. The lady with the necrotizing fasciitis, she was refusing to come to the hospital. By talking to the patient herself over the video, we were able to convince her that she needs higher level of care. When she arrived in our hospital she was in full septic shock. Steve Smith, M.D. (Roanoke, VA): I have spent the last 15 years of my career working in trauma centers that were surrounded by relatively small hospitals working under very austere circumstances so I can understand your passion. I have two questions for you. What about training of the outlying facilities? Have you taken the rural trauma team development course out to these facilities? Dave Kappel from West Virginia presented a paper recently at another meeting that showed that something as simple as introduction to the rural trauma team development course accomplished much of the same thing that you’ve talked about and I think quite honestly that would be less expensive as far as facilitating appropriate and timely transfer of patients. Secondly, I think that a couple of the obstacles that have interfered with the progression of this type of practice are continued fears or concerns about no reimbursement for the trauma center and increased liability for the trauma surgeons who are providing this on site guidance or consultation. Has any progress been made in this area? Dr. Latifi: Let me take the last question first because I think it is really crucial to address the issue of fear of liability. I believe that small hospitals will have less malpractice if they have you as the trauma expert seeing the patients and helping the resuscitation. Obviously, you dictate the note, and take responsibility for your advice and work closely with referring physician. So I think the use of telemedicine for trauma and emergency surgery will lower malpractice rate, although I have no data to support that yet. I have never heard of a case of telemedicine malpractice from trauma and I have been doing this now for a few years. We actually dictate a note and charge for this telemedicine consultation; it is very small, but nonetheless it is probably comparable with if they had come to our hospital. On training—we actually have done two types of training. Number one, we train all the doctors on telemedicine equipment and how to use it, but on the trauma issues as well. The conversation is between us trauma surgeons and a rural physician is changing. The rural providers are becoming more sophisticated, I believe due to our routine telemedicine consultations.