RESEARCH/Original article
A pilot trial of emergency telemedicine in regional Western Australia
Journal of Telemedicine and Telecare 19(7) 430–433 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506531 jtt.sagepub.com
Garth Herrington1, Yvonne Zardins1 and Alan Hamilton2
Summary An Emergency Telehealth Service (ETS) was established in August 2012 in Western Australia. High definition videoconferencing was used to deliver emergency telemedicine to rural emergency departments, mainly staffed by nurses. In the first 11 months, over 3000 episodes of care were provided. Telemedicine proved useful for many clinical problems and allowed clinicians to diagnose, treat and manage patients locally, reducing the need for transfer. In addition, ETS physicians assisted with clinical coordination and transfer of patients. Almost all teleconsultations (98%) were with nursing staff at sites without medical cover. Expansion of the ETS throughout Western Australia is currently being planned. Accepted: 26 August 2013
Introduction The Western Australian Country Health Service (WACHS) covers the largest area of Australia (2.6 million km2) and is made up of seven regions. Health services are provided through six regional hospitals which are larger centres with emergency medicine and other specialties, 15 medium-sized hospitals and 49 small hospitals which have varying degrees of non-specialist Emergency Department (ED) medical cover. In addition there are 47 nursing posts in regional and remote locations, and numerous community based health centres. The dispersed populations and regional isolation present significant challenges particularly in the provision of emergency care. In a 12-month period (financial year 2011/2012), nearly 400,000 emergency episodes of patient care were delivered in WACHS facilities. There are only three EDs with a specialist clinical workforce. Medical and nursing staff in smaller sites have varying experience with complex or emergency situations. The majority of WACHS sites are medically supported by general practitioners (GPs) who live locally and are contracted to provide medical services to patients at the hospital. These are often single-doctor towns and present challenges in terms of sustainability and recruitment. It is not uncommon for some sites to have no local medical cover at times, which means that nurses are reliant on telephone support. This is undesirable because delayed access to specialist care for emergency patients is associated with increased risk of morbidity and mortality and increased patient anxiety.1 Smaller rural sites receive a low volume of urgent or complex emergency cases, but when they occur they can present a challenge to local services with limited staff and resources. To obtain emergency medicine advice, sites may
seek advice from tertiary and regional hospitals, retrieval and subspecialty services. Hence there is need for consistent and high quality advice for rural and remote clinicians. Generally clinicians offering telephone advice are not in a position to contribute directly to the care of the patient in a remote location or assist in the coordination of transfer if required. The importance of having senior emergency physicians from a patient safety perspective and also from an efficiency point of view has been documented in a number of studies.2 The Emergency Telehealth Service (ETS) was established in order to provide an accessible, accountable source of specialist emergency medicine advice and support for clinicians in rural WA.
Emergency Telehealth Service The pilot project commenced with six sites and subsequently expanded to 25. The pilot sites included a regional hospital with a well resourced ED and inpatient beds, medium-sized facilities and smaller hospitals with no inpatient beds, see Table 1. The ETS workforce comprised 15 Emergency Medicine Specialists (Fellows of the Australasian College of Emergency Medicine, FACEM). High definition
1
Clinical Reform, WA Country Health Service, Perth, Australia WA Statewide Telehealth Service, Perth, Australia
2
Corresponding author: Yvonne Zardins, WA Country Health Service, PO Box 6680, East Perth BC 6892, Australia. Email: [email protected]
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
Herrington et al.
431
Table 1. ETS pilot sites. Type
Number of sites
Approximate number of ED cases annually
Regional hospital
1
29,000
Large multipurpose facility
2
12,000–14,000
Small multipurpose facility Small hospital
1 21
4000 300–2000
Description Regional hospital, ED with 24 hour non-specialist medical cover, 66 inpatient beds, other specialty services available such as obstetrics, surgical Multipurpose Service Sites* with ED, inpatient beds and some outpatient services, 24-hour ED roster with 12 hours on the floor and 12 hours on call with GP medical cover Multipurpose Service Sites* with limited medical cover for ED Small hospital with ED and up to 6 inpatient beds, on-call GP medical cover
*Multipurpose Service Sites are those where Commonwealth and State funds are pooled to deliver flexibility across all health and aged care programmes according to local need
Figure 1. Standardised cameras and videoconferencing equipment located in each participating ED.
videoconferencing equipment (HDX8000, Polycom) was installed in the resuscitation bays of the EDs receiving the ETS. One video camera was mounted above the foot of the bed providing a birds-eye view of the patient and another camera was mounted at 45 degrees to the foot of the bed providing an alternate view that could be panned and zoomed to show specific areas, see Figure 1. Similar videoconferencing equipment was used by the
provisioning doctor (HDX4500, Polycom). All videoconference calls are transmitted using IP at 1 Mbit/s delivering video at 1080P resolution. The equipment is activated and controlled by the doctor at the provider site. Receiving site staff are asked not to adjust or attempt to control the equipment. The configuration of the equipment is similar at all provider and receiving sites.
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
432
Journal of Telemedicine and Telecare 19(7)
ETS physicians provide the service from a central office and also remotely from doctors’ homes or regional hospital sites. The ETS operational hours were established to meet the need for medical assistance when local medical support was least likely to be available, i.e. outside the normal working day and at weekends. Consultations to the ETS may be initiated by nursing or medical staff. Nursing staff follow WACHS guidelines which require medical officer involvement in patient management, thus leading to ETS referral. Medical staff consult the ETS at their discretion. Most ETS sites are staffed by nurses alone; only 2% of ETS consultations have been provided to a medical practitioner. The implementation of the ETS has highlighted deficiencies in service provision, training, local equipment, processes and systems. There has been significant clinical service redesign and improvements in governance directly related to the establishment of the service. Processes and technology have been developed to enable the ETS physician to work independently, managing the consultation from its initiation through to the finalisation of documentation and its transmission to the on-site clinicians. Telephony and secure, stable, electronic communication of notes and orders facilitate proper accountability. ETS consultation requests are made by telephone if urgent or via a non-urgent request faxed to the ETS physician. Call centre telephony has been utilised to allow clinicians information as to the type and urgency of incoming calls. The system provides for scalability and the ability to route calls to multiple sites and provisioning clinicians. All consultations are documented by the ETS physician using standard hospital ED documentation which is faxed back to the site for inclusion in the patient’s medical record. Faxes are sent encrypted for security. Video consultations are not recorded (taped) and a verbal patient consent process is followed. Established WACHS quality and safety procedures have been applied to the ETS. Patients and staff involved in ETS consultations are provided with feedback forms, which are audited routinely. Significant clinical episodes are followed up by ETS staff to ensure quality and provide outcome data to the service.
Results The ETS has delivered over 3000 consultations during the initial 11 months of the trial varying in urgency and avoiding some form of travel for 66% of those patients. Over 2000 occasions of service have resulted in remote diagnosis and treatment. A total of 700 transfers have been facilitated. The ETS has demonstrated the ability of emergency telemedicine to diagnose, treat and manage a range of clinical problems. In the ETS pilot trial, the service was provided by Specialist Emergency Consultants. Existing referral pathways to obstetrics and neonatal care remained intact and ETS physicians did not take responsibility for these types of presentation. The overall governance and support of
remote staff always remained within the remit of the ETS clinician and on occasion the service participated in delivery of care involving the existing referral pathways to obstetrics and neonatal specialties. As the workload increases, it is anticipated that there will be a tiered service provision model with a mixture of ED Consultants, nonspecialist Medical Officers and Nurse Practitioners. The ETS has provided acute care remotely to assist local medical staff and nurses to better manage emergency patients. Patients in cardiac arrest, suffering acute myocardial infarction, complete heart block, various cardiac arrhythmias (VF, VT, AF) have been diagnosed and treated remotely. Various joint dislocations have been reduced by local staff with ETS involvement. Other procedures have been undertaken that would have not been possible without ETS advice and participation. An example of an acute case managed by the ETS with local staff demonstrates benefits of the ETS model of care: a 50-year-old man presented to a small hospital with chest pain. There was no doctor present and the patient was assessed initially by a Registered Nurse, assisted by an Enrolled Nurse. The ETS was consulted and the patient diagnosed as suffering an acute myocardial infarction (MI). Subsequently two episodes of ventricular fibrillation were followed by cardiac arrest. The resuscitation was directed by the ETS physician. Initially shocked and semi-conscious, the patient was successfully defibrillated twice with return of spontaneous circulation. The ETS physician directed significant high level interventions including airway management, thrombolysis, ionotropic support and medical management of the MI. At the initial presentation and diagnosis the ETS physician requested aero-medical retrieval and within an hour of presentation the patient was retrieved to Perth for further treatment. The nurses involved stated that the ETS physician participation allowed them to provide an extended level of care with a positive outcome. The patient had complete ECG resolution of the MI and underwent semi-acute angiography 24 hours later. He was discharged from hospital several days later with no neurological sequelae. Pathways for clinical advice and coordination in Western Australia are complex. Multiple telephone calls are required and the burden remains with the remote site which generally has the fewest staffing resources available. The presence of an experienced Emergency Physician via ETS has relieved some of this burden, allowing local staff to focus on caring for their patients. ETS staff often make earlier retrieval referrals, and facilitate this complicated process. Data are currently being collected about this element of the ETS. The expectation is that time to retrieval will be decreased and appropriateness of transfer will be improved by ETS involvement. Staff in remote sites have been enthusiastic about this element of the service. Anecdotal evidence suggests that benefits include increased confidence of nurses to treat patients appropriately in their EDs with specialist medical support. There also appears to be an increase in appropriate specialist
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
Herrington et al.
433
referrals, both in emergency and non-emergency consultations. The diagnostic abilities of the FACEM workforce that comes from their specialist knowledge and skills appears to improve emergency patient consultations by identifying patient conditions that will benefit from specialist referral.
Discussion
real-time learning that is facilitated by the model but also by the subsequent application of the integrated network across remote sites. Fewer transfers and less patient travel probably has economic benefits for the health service. Telemedicine enables a large area health service to address the demand for emergency medicine practitioners at numerous sites with varying presentation rates. Acknowledgements
Although it has yet to be subjected to a formal evaluation, the ETS has provided efficient specialist emergency services for the WACHS. Access to emergency medicine consultants has enhanced the ability of isolated nurses and GPs to deliver appropriate, safe care and enabled them to treat and manage patients locally thus avoiding travel and time away from home. The ETS has begun to address the problem of access and equity to specialist emergency care for rural patients by enabling one FACEM to deliver emergency medicine to 25 geographically dispersed sites. The experience of the ETS pilot is in agreement with a recent review that concluded that the ED setting is well suited to the application of telemedicine.3 The success of the ETS model presents the opportunity to improve the access of rural EDs to other specialties such as psychiatry, paediatrics and obstetrics. The potential for teaching opportunities to facilitate skill development and maintenance are not only evident in the
The pilot programme was funded by the West Australian State Government Royalties for Regions Program, Department of Regional Development (Southern Inland Health Initiative).
References 1. Rafman H, Lim SN, Quek SC, Mahadevan M, Lim C, Lim A. Using systematic change management to improve emergency patients’ access to specialist care: the Big Squeeze. Emerg Med J 2013;30:447–53. 2. Northern Rivers University Department of Rural Health. Literature review of emergency department staffing redesign frameworks. See http://www0.health.nsw.gov.au/pubs/2010/ pdf/EDWRP_EDW_Literature_Review_Final_Report_ Nov2009.pdf (last checked 17 August 2013). 3. Keane MG. A review of the role of telemedicine in the accident and emergency department. J Telemed Telecare 2009;15:132–134.
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
A pilot trial of emergency telemedicine in regional Western Australia
Journal of Telemedicine and Telecare 19(7) 430–433 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506531 jtt.sagepub.com
Garth Herrington1, Yvonne Zardins1 and Alan Hamilton2
Summary An Emergency Telehealth Service (ETS) was established in August 2012 in Western Australia. High definition videoconferencing was used to deliver emergency telemedicine to rural emergency departments, mainly staffed by nurses. In the first 11 months, over 3000 episodes of care were provided. Telemedicine proved useful for many clinical problems and allowed clinicians to diagnose, treat and manage patients locally, reducing the need for transfer. In addition, ETS physicians assisted with clinical coordination and transfer of patients. Almost all teleconsultations (98%) were with nursing staff at sites without medical cover. Expansion of the ETS throughout Western Australia is currently being planned. Accepted: 26 August 2013
Introduction The Western Australian Country Health Service (WACHS) covers the largest area of Australia (2.6 million km2) and is made up of seven regions. Health services are provided through six regional hospitals which are larger centres with emergency medicine and other specialties, 15 medium-sized hospitals and 49 small hospitals which have varying degrees of non-specialist Emergency Department (ED) medical cover. In addition there are 47 nursing posts in regional and remote locations, and numerous community based health centres. The dispersed populations and regional isolation present significant challenges particularly in the provision of emergency care. In a 12-month period (financial year 2011/2012), nearly 400,000 emergency episodes of patient care were delivered in WACHS facilities. There are only three EDs with a specialist clinical workforce. Medical and nursing staff in smaller sites have varying experience with complex or emergency situations. The majority of WACHS sites are medically supported by general practitioners (GPs) who live locally and are contracted to provide medical services to patients at the hospital. These are often single-doctor towns and present challenges in terms of sustainability and recruitment. It is not uncommon for some sites to have no local medical cover at times, which means that nurses are reliant on telephone support. This is undesirable because delayed access to specialist care for emergency patients is associated with increased risk of morbidity and mortality and increased patient anxiety.1 Smaller rural sites receive a low volume of urgent or complex emergency cases, but when they occur they can present a challenge to local services with limited staff and resources. To obtain emergency medicine advice, sites may
seek advice from tertiary and regional hospitals, retrieval and subspecialty services. Hence there is need for consistent and high quality advice for rural and remote clinicians. Generally clinicians offering telephone advice are not in a position to contribute directly to the care of the patient in a remote location or assist in the coordination of transfer if required. The importance of having senior emergency physicians from a patient safety perspective and also from an efficiency point of view has been documented in a number of studies.2 The Emergency Telehealth Service (ETS) was established in order to provide an accessible, accountable source of specialist emergency medicine advice and support for clinicians in rural WA.
Emergency Telehealth Service The pilot project commenced with six sites and subsequently expanded to 25. The pilot sites included a regional hospital with a well resourced ED and inpatient beds, medium-sized facilities and smaller hospitals with no inpatient beds, see Table 1. The ETS workforce comprised 15 Emergency Medicine Specialists (Fellows of the Australasian College of Emergency Medicine, FACEM). High definition
1
Clinical Reform, WA Country Health Service, Perth, Australia WA Statewide Telehealth Service, Perth, Australia
2
Corresponding author: Yvonne Zardins, WA Country Health Service, PO Box 6680, East Perth BC 6892, Australia. Email: [email protected]
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
Herrington et al.
431
Table 1. ETS pilot sites. Type
Number of sites
Approximate number of ED cases annually
Regional hospital
1
29,000
Large multipurpose facility
2
12,000–14,000
Small multipurpose facility Small hospital
1 21
4000 300–2000
Description Regional hospital, ED with 24 hour non-specialist medical cover, 66 inpatient beds, other specialty services available such as obstetrics, surgical Multipurpose Service Sites* with ED, inpatient beds and some outpatient services, 24-hour ED roster with 12 hours on the floor and 12 hours on call with GP medical cover Multipurpose Service Sites* with limited medical cover for ED Small hospital with ED and up to 6 inpatient beds, on-call GP medical cover
*Multipurpose Service Sites are those where Commonwealth and State funds are pooled to deliver flexibility across all health and aged care programmes according to local need
Figure 1. Standardised cameras and videoconferencing equipment located in each participating ED.
videoconferencing equipment (HDX8000, Polycom) was installed in the resuscitation bays of the EDs receiving the ETS. One video camera was mounted above the foot of the bed providing a birds-eye view of the patient and another camera was mounted at 45 degrees to the foot of the bed providing an alternate view that could be panned and zoomed to show specific areas, see Figure 1. Similar videoconferencing equipment was used by the
provisioning doctor (HDX4500, Polycom). All videoconference calls are transmitted using IP at 1 Mbit/s delivering video at 1080P resolution. The equipment is activated and controlled by the doctor at the provider site. Receiving site staff are asked not to adjust or attempt to control the equipment. The configuration of the equipment is similar at all provider and receiving sites.
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
432
Journal of Telemedicine and Telecare 19(7)
ETS physicians provide the service from a central office and also remotely from doctors’ homes or regional hospital sites. The ETS operational hours were established to meet the need for medical assistance when local medical support was least likely to be available, i.e. outside the normal working day and at weekends. Consultations to the ETS may be initiated by nursing or medical staff. Nursing staff follow WACHS guidelines which require medical officer involvement in patient management, thus leading to ETS referral. Medical staff consult the ETS at their discretion. Most ETS sites are staffed by nurses alone; only 2% of ETS consultations have been provided to a medical practitioner. The implementation of the ETS has highlighted deficiencies in service provision, training, local equipment, processes and systems. There has been significant clinical service redesign and improvements in governance directly related to the establishment of the service. Processes and technology have been developed to enable the ETS physician to work independently, managing the consultation from its initiation through to the finalisation of documentation and its transmission to the on-site clinicians. Telephony and secure, stable, electronic communication of notes and orders facilitate proper accountability. ETS consultation requests are made by telephone if urgent or via a non-urgent request faxed to the ETS physician. Call centre telephony has been utilised to allow clinicians information as to the type and urgency of incoming calls. The system provides for scalability and the ability to route calls to multiple sites and provisioning clinicians. All consultations are documented by the ETS physician using standard hospital ED documentation which is faxed back to the site for inclusion in the patient’s medical record. Faxes are sent encrypted for security. Video consultations are not recorded (taped) and a verbal patient consent process is followed. Established WACHS quality and safety procedures have been applied to the ETS. Patients and staff involved in ETS consultations are provided with feedback forms, which are audited routinely. Significant clinical episodes are followed up by ETS staff to ensure quality and provide outcome data to the service.
Results The ETS has delivered over 3000 consultations during the initial 11 months of the trial varying in urgency and avoiding some form of travel for 66% of those patients. Over 2000 occasions of service have resulted in remote diagnosis and treatment. A total of 700 transfers have been facilitated. The ETS has demonstrated the ability of emergency telemedicine to diagnose, treat and manage a range of clinical problems. In the ETS pilot trial, the service was provided by Specialist Emergency Consultants. Existing referral pathways to obstetrics and neonatal care remained intact and ETS physicians did not take responsibility for these types of presentation. The overall governance and support of
remote staff always remained within the remit of the ETS clinician and on occasion the service participated in delivery of care involving the existing referral pathways to obstetrics and neonatal specialties. As the workload increases, it is anticipated that there will be a tiered service provision model with a mixture of ED Consultants, nonspecialist Medical Officers and Nurse Practitioners. The ETS has provided acute care remotely to assist local medical staff and nurses to better manage emergency patients. Patients in cardiac arrest, suffering acute myocardial infarction, complete heart block, various cardiac arrhythmias (VF, VT, AF) have been diagnosed and treated remotely. Various joint dislocations have been reduced by local staff with ETS involvement. Other procedures have been undertaken that would have not been possible without ETS advice and participation. An example of an acute case managed by the ETS with local staff demonstrates benefits of the ETS model of care: a 50-year-old man presented to a small hospital with chest pain. There was no doctor present and the patient was assessed initially by a Registered Nurse, assisted by an Enrolled Nurse. The ETS was consulted and the patient diagnosed as suffering an acute myocardial infarction (MI). Subsequently two episodes of ventricular fibrillation were followed by cardiac arrest. The resuscitation was directed by the ETS physician. Initially shocked and semi-conscious, the patient was successfully defibrillated twice with return of spontaneous circulation. The ETS physician directed significant high level interventions including airway management, thrombolysis, ionotropic support and medical management of the MI. At the initial presentation and diagnosis the ETS physician requested aero-medical retrieval and within an hour of presentation the patient was retrieved to Perth for further treatment. The nurses involved stated that the ETS physician participation allowed them to provide an extended level of care with a positive outcome. The patient had complete ECG resolution of the MI and underwent semi-acute angiography 24 hours later. He was discharged from hospital several days later with no neurological sequelae. Pathways for clinical advice and coordination in Western Australia are complex. Multiple telephone calls are required and the burden remains with the remote site which generally has the fewest staffing resources available. The presence of an experienced Emergency Physician via ETS has relieved some of this burden, allowing local staff to focus on caring for their patients. ETS staff often make earlier retrieval referrals, and facilitate this complicated process. Data are currently being collected about this element of the ETS. The expectation is that time to retrieval will be decreased and appropriateness of transfer will be improved by ETS involvement. Staff in remote sites have been enthusiastic about this element of the service. Anecdotal evidence suggests that benefits include increased confidence of nurses to treat patients appropriately in their EDs with specialist medical support. There also appears to be an increase in appropriate specialist
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
Herrington et al.
433
referrals, both in emergency and non-emergency consultations. The diagnostic abilities of the FACEM workforce that comes from their specialist knowledge and skills appears to improve emergency patient consultations by identifying patient conditions that will benefit from specialist referral.
Discussion
real-time learning that is facilitated by the model but also by the subsequent application of the integrated network across remote sites. Fewer transfers and less patient travel probably has economic benefits for the health service. Telemedicine enables a large area health service to address the demand for emergency medicine practitioners at numerous sites with varying presentation rates. Acknowledgements
Although it has yet to be subjected to a formal evaluation, the ETS has provided efficient specialist emergency services for the WACHS. Access to emergency medicine consultants has enhanced the ability of isolated nurses and GPs to deliver appropriate, safe care and enabled them to treat and manage patients locally thus avoiding travel and time away from home. The ETS has begun to address the problem of access and equity to specialist emergency care for rural patients by enabling one FACEM to deliver emergency medicine to 25 geographically dispersed sites. The experience of the ETS pilot is in agreement with a recent review that concluded that the ED setting is well suited to the application of telemedicine.3 The success of the ETS model presents the opportunity to improve the access of rural EDs to other specialties such as psychiatry, paediatrics and obstetrics. The potential for teaching opportunities to facilitate skill development and maintenance are not only evident in the
The pilot programme was funded by the West Australian State Government Royalties for Regions Program, Department of Regional Development (Southern Inland Health Initiative).
References 1. Rafman H, Lim SN, Quek SC, Mahadevan M, Lim C, Lim A. Using systematic change management to improve emergency patients’ access to specialist care: the Big Squeeze. Emerg Med J 2013;30:447–53. 2. Northern Rivers University Department of Rural Health. Literature review of emergency department staffing redesign frameworks. See http://www0.health.nsw.gov.au/pubs/2010/ pdf/EDWRP_EDW_Literature_Review_Final_Report_ Nov2009.pdf (last checked 17 August 2013). 3. Keane MG. A review of the role of telemedicine in the accident and emergency department. J Telemed Telecare 2009;15:132–134.
Downloaded from jtt.sagepub.com at East Carolina University on April 25, 2015
