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Pediatrics International (2014) 56, 644–646
doi: 10.1111/ped.12393
Brief Report
Increased satisfaction of maternity hospital staff involved in fetal telediagnosis Takashi Hishitani, Fumie Kawachi, Yoshitaka Fujimoto, Kenji Sugamoto, Kenji Hoshino and Kiyoshi Ogawa Department of Cardiology, Saitama Children’s Medical Center, Saitama, Japan Abstract
Questionnaires were sent to 14 maternity hospital staff members for qualitative assessment at the start of fetal telediagnosis and at the end of the study using a five-point Likert scale: 5, I strongly think so; 4, I think so; 3, I can’t decide; 2, I don’t think so; 1, I never think so. Ten questionnaires were returned to us (71%). The results showed that the staff reported a significant increase in confidence in performing fetal cardiac screening (score 2.3 at start, 3.4 at study completion; P = 0.034), the rate of score increase rose with the number of telediagnoses (r = 0.72, P < 0.05), feedback from a specialist was very useful (4.4 and 4.9, respectively), and real-time image transmission was preferred over recorded images (score 3.7 vs 2.4, respectively; P = 0.042). The excellent educational effect of telemedicine is useful for staff members to improve their skills while nurturing their motivation, leading to the promotion of fetal cardiac screening in regional areas.
Key words education, fetal echocardiography, fetal telediagnosis, medical link, questionnaire.
Telemedicine using high-performance ultrasound has recently been developed. Correctly diagnosing a fetus in the uterus could reduce neonatal and infantile deaths. We established a fetal telediagnosis system with virtual private network (VPN) between district maternity hospitals and Saitama Children’s Medical Center, and started its formal operation on 1 October 2009. We recently reported the effect of telediagnosis with high-quality images transmission (network speed: 6000 kbps, maximum frame rate: 30 fps), through which many severe cases were identified in maternity hospitals with a specialist’s support provided via the Internet and transferred to tertiary centers, while the number of emergent neonatal transportations continued to be low.1 One hundred and sixty telediagnoses (155 fetuses) were performed between 1 October 2009 and 5 November 2013 between Saitama Children’s Medical Center and six maternity hospitals (presently nine hospitals, including three hospitals with fewer than 19 beds). Of these, the reasons for 140 telediagnoses were suspected cardiac disease, and 15 real-time and 145 recordedimage transmissions were conducted. We sent questionnaires to the maternity hospital staff in October 2013 to assess their attitudes regarding involvement in fetal telediagnosis. Equipment and process of telediagnosis
As previously reported in detail,1 fetal echocardiography was carried out using a teleconference system (NTT Meeting Plaza Correspondence: Takashi Hishitani, MD, Department of Cardiology, Saitama Children’s Medical Center, Magome 2100, Iwatsuki, Saitamashi, Saitama 339-8551, Japan. Email: hishitani.takashi@pref .saitama.lg.jp Received 9 January 2014; revised 29 March 2014; accepted 12 May 2014.
© 2014 Japan Pediatric Society
ver. 4.5 [ver. 6.0 from April 2012]) with optical fiber transmission of recorded ultrasound images stored on a DVD or spatiotemporal image correlation (STIC) images, or real-time images between Saitama Children’s Medical Center and the other maternity hospitals. Maternity hospital staff participated in this system using headphones, a microphone, and a web camera (Fig. 1). This new technique for diagnosis was approved by the ethics committee of Saitama Children’s Medical Center in January 2009, and informed consent was obtained, especially from expectant parents participating in real-time telediagnosis at each maternity hospital according to the procedures and responsibility.
Methods A structured Likert scale questionnaire was sent to the maternity hospital staff participating in the fetal telediagnosis program and was completed by them. The questionnaire consisted of 10 questions related to their own improvements in techniques of fetal echocardiology, sufficient explanation of the results and the necessity of mental care for participating women, opportunities for workshops using telemedicine, and free description. A focus on the educational aspect of telemedicine was set using the first six questions in this study. Qualitative assessment was conducted by the staff using a five-point Likert scale at the start of fetal telediagnosis and at the end of the study. The five-point scale was as follows: 5, I strongly think so; 4, I think so; 3, I can’t decide; 2, I don’t think so; 1, I never think so. Statistical analysis
Statistical analysis was performed using the Wilcoxon-signed rank test. A P-value < 0.05 was considered significant.
Staff satisfaction in fetal telediagnosis
645
Fig. 1 Telediagnosis was performed by discussion using headphones and a microphone, and echocardiographic images were transmitted via the Internet.
Results Questionnaires were sent to 14 maternity hospital staff members, and 10 were returned to us (71%, seven obstetricians and three sonographers). Nine questionnaires, excluding one from a hospital director who does not usually perform fetal echo examination, were analyzed for further assessment. Participants’ years of experience of fetal cardiac screening were as follows: four staff, 1–5 years; three staff, 5–10 years; and two staff, >10. The number of fetal telediagnoses performed were: five staff, 1–9; one staff, 10–19; two staff, 30–39; and 1 staff, 40–49. The years of experience in fetal telediagnosis were: 30.6 ± 19.5 months. The results of qualitative assessment by the staff are shown in Table 1. The staff participating in the program reported a significant increase in confidence for performing fetal cardiac screening (score 2.3 at start, 3.4 at study completion; P = 0.034). The rate of the score increase, which was analyzed in all but two staff whose score was already 4 at the start, rose along with the number of telediagnoses (r = 0.72, P < 0.05), but showed no association with the years of experience in fetal telediagnosis (r = 0.22). The staff were already aware at the start that feedback from a specialist was very useful, and they could communicate well with specialists using headphones, a microphone, and the transmitted images (score 4.4 and 3.8 at start, respectively).
Some staff felt stressed (mean score: 3.1) about using telemedicine equipment at the start in spite of receiving a prior explanation on how to use it, but were getting used to it to some extent (score 3.8 at study end).
Table 1 Qualitative assessment by the staff participating in the fetal telediagnosis program Mean Likert score (1–5) 1. I can perform fetal cardiac screening 2. The feedback from a specialist is useful 3. I can use telemedicine equipment with less stress 4. I can communicate well with a specialist using the headphones, microphones, and transmitted images 5. Real-time image transmission is superior 6. Recorded-image transmission is superior
Start 2.3
Study end 3.4 (P = 0.034)
4.4
4.9 (P > 0.10)
3.1
3.8 (P > 0.10)
3.8
4.1 (P > 0.10)
3.7*
3.7**
2.4*
2.4**
*P = 0.042; **P = 0.042.
© 2014 Japan Pediatric Society
646
T Hishitani et al.
Real-time image transmission was preferred over recorded images because they could directly receive helpful guidance from a specialist, although it required a rather longer communication time (score 3.7 vs 2.4, respectively, P = 0.042; same result at start and study end).
Discussion The analysis of the questionnaires showed that the confidence of staff significantly increased for performing fetal cardiac screening, they were satisfied with receiving immediate feedback from a specialist, and most of them preferred real-time image transmission. In our recent report, we showed that educational feedback to maternity hospital staff while making a telediagnosis with the assistance of a pediatric cardiologist led to advancement of their fetal ultrasound techniques and knowledge of fetal cardiology, and to a decrease in the number of neonatal emergent transportations.1 Based on the above results, we cast a spotlight on the educational aspect of telediagnosis in this report. According to the questionnaire results, the staff showed a significant increase in confidence to perform fetal cardiac screening. The rate of score increase significantly rose (P < 0.05) with an increase in the number of telediagnoses. This excellent educational effect of telemedicine was also reported by McCrossan, in which radiographers were highly satisfied with their involvement in the study, feeling increased confidence in detecting congenital heart disease at the end-point.2 The staff felt satisfaction in terms of receiving immediate feedback from a specialist while making a diagnosis based on verbal communication and transmitted images. This satisfaction was seen from the start, and was higher with real-time image transmission. As Simpson described in an editorial comment,3 if immediate feedback can be given, telemedicine may provide valuable reassurance faster than if the patient travels to a tertiary center. For real-time transmission, it took much longer to obtain live images of a good enough quality to assess the heart of a moving fetus compared to recorded image transmission in which key images had already been stored, and it took additional time to explain the results to the family members. The time required for real-time transmission in our cases was much longer (approximately 30 min) than in McCrossan’s report (mean duration: 13.9 min).2 Nonetheless, most maternity hospital staff preferred real-time transmission because they thought that they could improve their skills in practicing fetal cardiac echo under the
© 2014 Japan Pediatric Society
direct guidance of a specialist. In a previous report, off-line STIC analysis was not accurate enough to use in clinical decisionmaking.4 We made a verbal telediagnosis online with transferred STIC images being manipulated by the maternity hospital staff. This online method is thought to be superior to offline STIC analysis in terms of both the diagnostic accuracy and educational aspects. Further research is needed on how to establish medical links between maternity hospitals and a tertiary medical center in widespread regions using a telediagnosis system, and at the same time, we should address the issues of the cost of consultation of a specialist, and the responsibility of diagnosis. Limitations of the study
The sample size of this study was small, partly because the collection rate was low (71%), which may have influenced statistical analysis. Also, the number of real-time image transmissions was much smaller than recorded-image transmissions, which might have influenced the comparison between these two methods.
Acknowledgments We are grateful to Dr Kino, Ms Inage and Ms Tanaka at Kino Maternity Clinic, Dr Matsumoto, Dr Kitagawa, and Ms Yoshikoshi at Sannoh Clinic, Dr Segawa, Ms Taguchi, Ms Maruyama, Ms Terauchi, and Ms Funakawa at Y’s Lady’s Clinic, Dr Atsukawa at Atsukawa Clinic, Dr Nemoto at Kuwajima Lady’s Clinic, Dr Sugawara and Dr Okamura at Sugawara Maternity Clinic, and Dr Nishioka at the Department of Obstetrics & Gynecology at Koshigaya Municipal Hospital. We received funding from the Kawano Masanori Memorial Foundation for Promotion of Pediatrics.
References 1 Hishitani T, Fujimoto Y, Saito Y, Sugamoto K, Hoshino K, Ogawa K. A medical link between local maternity hospitals and a tertiary center using telediagnosis with fetal cardiac ultrasound image transmission. Pediatr. Cardiol. 2014; 35 (4): 652–7. 2 McCrossan BA, Sands AJ, Kileen T, Cardwell CR, Casey FA. Fetal diagnosis of congenital heart disease by telemedicine. Arch. Dis. Child. Fetal Neonatal Ed. 2011; 96: F394–7. 3 Simpson JM. The role of telemedicine in a fetal cardiology service. Arch. Dis. Child Fetal Neonatal Ed. 2011; 96: F392–3. 4 Adriaanse BME, Tromp CHN, Simpson JM et al. Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation. Ultrasound Obstet. Gynecol. 2012; 39: 203–9.
Pediatrics International (2014) 56, 644–646
doi: 10.1111/ped.12393
Brief Report
Increased satisfaction of maternity hospital staff involved in fetal telediagnosis Takashi Hishitani, Fumie Kawachi, Yoshitaka Fujimoto, Kenji Sugamoto, Kenji Hoshino and Kiyoshi Ogawa Department of Cardiology, Saitama Children’s Medical Center, Saitama, Japan Abstract
Questionnaires were sent to 14 maternity hospital staff members for qualitative assessment at the start of fetal telediagnosis and at the end of the study using a five-point Likert scale: 5, I strongly think so; 4, I think so; 3, I can’t decide; 2, I don’t think so; 1, I never think so. Ten questionnaires were returned to us (71%). The results showed that the staff reported a significant increase in confidence in performing fetal cardiac screening (score 2.3 at start, 3.4 at study completion; P = 0.034), the rate of score increase rose with the number of telediagnoses (r = 0.72, P < 0.05), feedback from a specialist was very useful (4.4 and 4.9, respectively), and real-time image transmission was preferred over recorded images (score 3.7 vs 2.4, respectively; P = 0.042). The excellent educational effect of telemedicine is useful for staff members to improve their skills while nurturing their motivation, leading to the promotion of fetal cardiac screening in regional areas.
Key words education, fetal echocardiography, fetal telediagnosis, medical link, questionnaire.
Telemedicine using high-performance ultrasound has recently been developed. Correctly diagnosing a fetus in the uterus could reduce neonatal and infantile deaths. We established a fetal telediagnosis system with virtual private network (VPN) between district maternity hospitals and Saitama Children’s Medical Center, and started its formal operation on 1 October 2009. We recently reported the effect of telediagnosis with high-quality images transmission (network speed: 6000 kbps, maximum frame rate: 30 fps), through which many severe cases were identified in maternity hospitals with a specialist’s support provided via the Internet and transferred to tertiary centers, while the number of emergent neonatal transportations continued to be low.1 One hundred and sixty telediagnoses (155 fetuses) were performed between 1 October 2009 and 5 November 2013 between Saitama Children’s Medical Center and six maternity hospitals (presently nine hospitals, including three hospitals with fewer than 19 beds). Of these, the reasons for 140 telediagnoses were suspected cardiac disease, and 15 real-time and 145 recordedimage transmissions were conducted. We sent questionnaires to the maternity hospital staff in October 2013 to assess their attitudes regarding involvement in fetal telediagnosis. Equipment and process of telediagnosis
As previously reported in detail,1 fetal echocardiography was carried out using a teleconference system (NTT Meeting Plaza Correspondence: Takashi Hishitani, MD, Department of Cardiology, Saitama Children’s Medical Center, Magome 2100, Iwatsuki, Saitamashi, Saitama 339-8551, Japan. Email: hishitani.takashi@pref .saitama.lg.jp Received 9 January 2014; revised 29 March 2014; accepted 12 May 2014.
© 2014 Japan Pediatric Society
ver. 4.5 [ver. 6.0 from April 2012]) with optical fiber transmission of recorded ultrasound images stored on a DVD or spatiotemporal image correlation (STIC) images, or real-time images between Saitama Children’s Medical Center and the other maternity hospitals. Maternity hospital staff participated in this system using headphones, a microphone, and a web camera (Fig. 1). This new technique for diagnosis was approved by the ethics committee of Saitama Children’s Medical Center in January 2009, and informed consent was obtained, especially from expectant parents participating in real-time telediagnosis at each maternity hospital according to the procedures and responsibility.
Methods A structured Likert scale questionnaire was sent to the maternity hospital staff participating in the fetal telediagnosis program and was completed by them. The questionnaire consisted of 10 questions related to their own improvements in techniques of fetal echocardiology, sufficient explanation of the results and the necessity of mental care for participating women, opportunities for workshops using telemedicine, and free description. A focus on the educational aspect of telemedicine was set using the first six questions in this study. Qualitative assessment was conducted by the staff using a five-point Likert scale at the start of fetal telediagnosis and at the end of the study. The five-point scale was as follows: 5, I strongly think so; 4, I think so; 3, I can’t decide; 2, I don’t think so; 1, I never think so. Statistical analysis
Statistical analysis was performed using the Wilcoxon-signed rank test. A P-value < 0.05 was considered significant.
Staff satisfaction in fetal telediagnosis
645
Fig. 1 Telediagnosis was performed by discussion using headphones and a microphone, and echocardiographic images were transmitted via the Internet.
Results Questionnaires were sent to 14 maternity hospital staff members, and 10 were returned to us (71%, seven obstetricians and three sonographers). Nine questionnaires, excluding one from a hospital director who does not usually perform fetal echo examination, were analyzed for further assessment. Participants’ years of experience of fetal cardiac screening were as follows: four staff, 1–5 years; three staff, 5–10 years; and two staff, >10. The number of fetal telediagnoses performed were: five staff, 1–9; one staff, 10–19; two staff, 30–39; and 1 staff, 40–49. The years of experience in fetal telediagnosis were: 30.6 ± 19.5 months. The results of qualitative assessment by the staff are shown in Table 1. The staff participating in the program reported a significant increase in confidence for performing fetal cardiac screening (score 2.3 at start, 3.4 at study completion; P = 0.034). The rate of the score increase, which was analyzed in all but two staff whose score was already 4 at the start, rose along with the number of telediagnoses (r = 0.72, P < 0.05), but showed no association with the years of experience in fetal telediagnosis (r = 0.22). The staff were already aware at the start that feedback from a specialist was very useful, and they could communicate well with specialists using headphones, a microphone, and the transmitted images (score 4.4 and 3.8 at start, respectively).
Some staff felt stressed (mean score: 3.1) about using telemedicine equipment at the start in spite of receiving a prior explanation on how to use it, but were getting used to it to some extent (score 3.8 at study end).
Table 1 Qualitative assessment by the staff participating in the fetal telediagnosis program Mean Likert score (1–5) 1. I can perform fetal cardiac screening 2. The feedback from a specialist is useful 3. I can use telemedicine equipment with less stress 4. I can communicate well with a specialist using the headphones, microphones, and transmitted images 5. Real-time image transmission is superior 6. Recorded-image transmission is superior
Start 2.3
Study end 3.4 (P = 0.034)
4.4
4.9 (P > 0.10)
3.1
3.8 (P > 0.10)
3.8
4.1 (P > 0.10)
3.7*
3.7**
2.4*
2.4**
*P = 0.042; **P = 0.042.
© 2014 Japan Pediatric Society
646
T Hishitani et al.
Real-time image transmission was preferred over recorded images because they could directly receive helpful guidance from a specialist, although it required a rather longer communication time (score 3.7 vs 2.4, respectively, P = 0.042; same result at start and study end).
Discussion The analysis of the questionnaires showed that the confidence of staff significantly increased for performing fetal cardiac screening, they were satisfied with receiving immediate feedback from a specialist, and most of them preferred real-time image transmission. In our recent report, we showed that educational feedback to maternity hospital staff while making a telediagnosis with the assistance of a pediatric cardiologist led to advancement of their fetal ultrasound techniques and knowledge of fetal cardiology, and to a decrease in the number of neonatal emergent transportations.1 Based on the above results, we cast a spotlight on the educational aspect of telediagnosis in this report. According to the questionnaire results, the staff showed a significant increase in confidence to perform fetal cardiac screening. The rate of score increase significantly rose (P < 0.05) with an increase in the number of telediagnoses. This excellent educational effect of telemedicine was also reported by McCrossan, in which radiographers were highly satisfied with their involvement in the study, feeling increased confidence in detecting congenital heart disease at the end-point.2 The staff felt satisfaction in terms of receiving immediate feedback from a specialist while making a diagnosis based on verbal communication and transmitted images. This satisfaction was seen from the start, and was higher with real-time image transmission. As Simpson described in an editorial comment,3 if immediate feedback can be given, telemedicine may provide valuable reassurance faster than if the patient travels to a tertiary center. For real-time transmission, it took much longer to obtain live images of a good enough quality to assess the heart of a moving fetus compared to recorded image transmission in which key images had already been stored, and it took additional time to explain the results to the family members. The time required for real-time transmission in our cases was much longer (approximately 30 min) than in McCrossan’s report (mean duration: 13.9 min).2 Nonetheless, most maternity hospital staff preferred real-time transmission because they thought that they could improve their skills in practicing fetal cardiac echo under the
© 2014 Japan Pediatric Society
direct guidance of a specialist. In a previous report, off-line STIC analysis was not accurate enough to use in clinical decisionmaking.4 We made a verbal telediagnosis online with transferred STIC images being manipulated by the maternity hospital staff. This online method is thought to be superior to offline STIC analysis in terms of both the diagnostic accuracy and educational aspects. Further research is needed on how to establish medical links between maternity hospitals and a tertiary medical center in widespread regions using a telediagnosis system, and at the same time, we should address the issues of the cost of consultation of a specialist, and the responsibility of diagnosis. Limitations of the study
The sample size of this study was small, partly because the collection rate was low (71%), which may have influenced statistical analysis. Also, the number of real-time image transmissions was much smaller than recorded-image transmissions, which might have influenced the comparison between these two methods.
Acknowledgments We are grateful to Dr Kino, Ms Inage and Ms Tanaka at Kino Maternity Clinic, Dr Matsumoto, Dr Kitagawa, and Ms Yoshikoshi at Sannoh Clinic, Dr Segawa, Ms Taguchi, Ms Maruyama, Ms Terauchi, and Ms Funakawa at Y’s Lady’s Clinic, Dr Atsukawa at Atsukawa Clinic, Dr Nemoto at Kuwajima Lady’s Clinic, Dr Sugawara and Dr Okamura at Sugawara Maternity Clinic, and Dr Nishioka at the Department of Obstetrics & Gynecology at Koshigaya Municipal Hospital. We received funding from the Kawano Masanori Memorial Foundation for Promotion of Pediatrics.
References 1 Hishitani T, Fujimoto Y, Saito Y, Sugamoto K, Hoshino K, Ogawa K. A medical link between local maternity hospitals and a tertiary center using telediagnosis with fetal cardiac ultrasound image transmission. Pediatr. Cardiol. 2014; 35 (4): 652–7. 2 McCrossan BA, Sands AJ, Kileen T, Cardwell CR, Casey FA. Fetal diagnosis of congenital heart disease by telemedicine. Arch. Dis. Child. Fetal Neonatal Ed. 2011; 96: F394–7. 3 Simpson JM. The role of telemedicine in a fetal cardiology service. Arch. Dis. Child Fetal Neonatal Ed. 2011; 96: F392–3. 4 Adriaanse BME, Tromp CHN, Simpson JM et al. Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation. Ultrasound Obstet. Gynecol. 2012; 39: 203–9.
