TRAUMA SYSTEM
Rural Trauma Telemedicine James Bryan Wesson, APRN, CNS-BC ■ Betty Kupperschmidt, EdD, RN, NEA-BC
ABSTRACT Telemedicine is the ability to provide remote health care to patients with the use of a consultant and 2-way interactive technology and telecommunication. Traumatic injuries occurring in rural areas frequently carry a greater risk of mortality than those same injuries occurring in the urban settings. The purpose of this article was to increase practitioner awareness of the potential for improved outcomes as a result of the use of telemedicine in rural trauma care. The use of trauma telemedicine will help decrease the overall mortality and morbidity, length of stay at the urban trauma centers, patient care cost, and transfer time.
Key Words Outcomes, Rural trauma care, Telemedicine
R
ural trauma care is a compelling concern for both authors. One author (BW) works in a large, tertiary facility from which telemedicine consultation is provided for rural trauma patients, whereas the other author (BK) worked for many years as the house supervisor in a rural community hospital. In this capacity, she (BK) had administrative and supervisory oversight of the facility and the emergency room, which meant triaging trauma patients in the absence of physicians and ancillary support. Critically injured patients were stabilized, which might take as long as an hour or more, and transferred to trauma centers approximately 35 to 50 miles away. The question must be asked: If telemedicine consults had been available, would the patient outcomes have been more positive? Currently, many rural practitioners may have limited opportunities to care for major trauma patients compared with colleagues practicing in urban trauma centers.1 For the practitioners, limited opportunities for care provision may
Author Affiliations: St John Health System, University of Oklahoma Health Science Center, Broken Arrow, Oklahoma (Mr Wesson); and University of Oklahoma Health Science Center, Broken Arrow, Oklahoma (Dr Kupperschmidt). The authors declare no conflicts of interest. Correspondence: James Bryan Wesson, APRN, CNS-BC, University of Oklahoma Health Science Center, 2828 North Lions Dr, Broken Arrow, OK 74012 ([email protected]). DOI: 10.1097/JTN.0000000000000012
JOURNAL OF TRAUMA NURSING
result in deceased competency level of skills essential when caring for trauma patients. For the patient, this limited exposure could result in an increased length of stay, morbidity, and costs as well as delays in transfer to tertiary centers. Increasing awareness of various strategies that rural hospital nurses and physicians may incorporate into their practice will lead to evidence-based care in the rural setting with improved patient care outcomes (see Tables 1 and 2).
PURPOSE Some form of telemedicine has been in use since the early 1900s, beginning with the use of 2-way radios and progressing to the use of interactive real-time technology.6 Telemedicine can be extremely beneficial for those individuals living in remote/rural-isolated communities. Use of this technology may provide access to medical care that might not be available to rural patients and provide education for health care practitioners. When rural-dwelling individuals experience major trauma, the community hospital may be unprepared to handle the complex care demanded by the patient’s injuries. This inability to provide the care needed may be the result of the lack of opportunity to care for trauma patients, and thus opportunities to maintain one’s knowledge base and competencies, and not provider incompetence. It is incumbent upon providers to acknowledge their competencies or lack of these essential competencies when caring for the trauma patient. Paramount in these competencies is the ability to quickly assess which patients can be safely managed at the local level and those patients who must be transferred to a trauma center. Physicians and nurses have an ethical obligation to all patients to avoid causing further harm and provide optimal evidence-based trauma care. This care must be provided regardless of race, creed, color, or the ability to pay.
Value of Telemedicine Telemedicine implemented in rural communities has been shown to significantly impact care by decreasing trauma center cost and increasing patient days in community hospitals, and venue for both facilities.7 Telemedicine has the potential to eliminate unnecessary cost and poor patient outcomes incurred when patient transfers to urban centers are delayed. With telemedicine, more severely injured patients are identified quickly and rapidly transferred to trauma centers. The consultant and trauma centers dedicated to caring for critically ill/severely injured WWW.JOURNALOFTRAUMANURSING.COM
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trauma patients can quickly and expertly provide the care demanded by these severely injured patients. Keeping patients who can be safely and expertly cared for at this level in community settings avoids the inconvenience of time away from family members incurred when patients are needlessly transferred to trauma centers. Strategies rural providers can use to facilitate their ability to provide this optimum trauma care are discussed in the next paragraphs.
Telemedicine Telemedicine is an innovative strategy that is currently being used in many situations. Telemedicine refers to use of a consultant based in a trauma center (this center may be in the same state or a different state) that interacts and consults with the rural providers (physicians and registered nurses) via interactive technology. For the purposes of this article, these physicians at trauma centers are referred to as consultants. The consultant may be a board-certified critical care-trained trauma surgeon, a fellow, or a resident, who for the purposes of this article interacts with rural care providers at all stages of patient care (triage to transfer). Establishment of telemedicine systems in rural emergency departments enables primary care providers to receive immediate life-saving advice or instruction from the consultant.8 During the initial assessment phase and resuscitation, the consultant may be able to defer timeconsuming procedures and expedite transfer to the trauma center.8 With telemedicine in place, the consultant is able to answer the staff’s questions and provide immediate feedback from the remote site.6 For example, the consultant may provide support and guidance for airway management, fluid resuscitation, and early administration of blood products and recommended best practice for reversal of therapeutic anticoagulation.8 Telemedicine facilitates a speedy, safe transition from the rural setting to the urban trauma center and avoids untimely delays. At all levels of care, effective communication is an essential prerequisite for safe, effective care. Selected strategies to foster effective communication are discussed in the next paragraph.
Effective Communication Effective communication is a key component of interdisciplinary collaboration and teamwork, and is essential for quality patient care. Regardless of the setting, poor communication undermines a collaborative organizational culture and contributes to increased clinical errors, poor patient outcomes, and provider dissatisfaction. Crawford et al9 proposed strategies to support and facilitate a collegial nurse/physician relationship. These strategies (see Table 3) include treating each other with respect and using a structured tool to focus communication on the patient (such as situation–background–assessment recommendation) and specific procedures to eliminate 200
WWW.JOURNALOFTRAUMANURSING.COM
unnecessary phone calls. When a nonhierarchical and collaborative relationship exists, the main focus becomes the patient. It is essential that interdisciplinary collaboration occur at all levels among staff at each facility. Ineffective communication may jeopardize the ability of the consultant to provide the timely, effective consultation demanded by the patients’ injuries. Thus, all personnel must share one common focus—the patient. As nurses and physicians become increasingly competent with core competencies for effective communication including the suggestions offered by Crawford (Table 3), they will be better able to establish collaborative interprofessional relationships. Two key elements necessary for collaborative cultures are language (how people speak to each other) and behavior (how people treat each other).9
Liability Issues Issues of licensure and other liability issues must be considered. For example, if the consultant is based in another state or country, certification and licensure requirements may vary. Thus, it is crucial that both settings identify and address these requirements to ensure that there are no discrepancies.
Cost Incurred With Implementing and Sustaining Telemedicine Implementing and sustaining telemedicine infrastructure comes at a significant initial cost. A telemedicine system requires hardware, software, and other communication commodities to function.10 Grants are available through the Department of Health and Human Services to provide technical assistance in the development of telehealth services in rural communities.11 These grant funds allow hospitals to either purchase or lease equipment or install equipment and to operate and evaluate the telehealth systems.11 These grants do require quantitative outcome studies to measure the impact on quality of care, the appropriateness of use of the technology, whether care access and clinical outcomes were improved, and the extent to which the cost of service delivery was affected in terms of efficiency and effectiveness of care.11 Cost-effectiveness is based on the concept of incremental costs and/or incremental outcomes.10 Incremental cost refers to the cost difference of telemedicine being implemented versus the alternative of not being implemented.10 An incremental outcome refers to improvement or lack of improvement once telemedicine has been implemented.10 A longitudinal study of 814 trauma patients (pretelemedicine, n = 351; and posttelemedicine, n = 463) was conducted. Pretelemedicine, patients who presented to the local community hospital were evaluated by either a physician or a nurse practitioner. All of these patients were transferred to the trauma center for Volume 20 | Number 4 | October–December 2013
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TABLE 1
Resources to Facilitate Rural Registered Nurses’ Competency With Trauma Care
Basic Life Support2 Advanced Cardiac Life Support2 Trauma Nurse Core Course3 Pediatric Advance Life Support2 Rural Trauma Team Development4 Advance Trauma Care for Nurses5
definitive management. Posttelemedicine, trauma patients were seen and telemedicine consults were obtained from the trauma center; of 463 of these patients, 63 (13.6%) of the patients were admitted to the local community hospital, 51 (11%) were transferred to the trauma center, 284 patients were discharged home, 15 patients left against medical advice, a patient died, and a few were transferred to another local community hospital. There was no data reported on 44 patients initially treated at the community hospital. Overall, there was a dramatic decrease in hospital cost. Posttelemedicine, the total cost was $1 126 683 when compared with the pretelemedicine cost of $7 632 624, which represented a significant cost savings of $6 505 941.7
CONCLUSION Implementation of rural trauma telemedicine is decidedly beneficial for nurses and physicians providing trauma care as well as for the recipients of that care. Heinzelmann and colleagues12 conducted a review of clinical outcomes associated with rural telemedicine. Although they decried the dearth of sound methodological research designs, they asserted that their review affirmed the importance of telemedicine. They found that higher levels of care were provided through telemedicine, and in several instances, potential planned transfers were avoided. In addition, these authors forecasted a bright future for telemedicine on the basis of the advances in telecommunication networks and concomitant transmission of increasingly highquality images.
TABLE 2
Resources to Facilitate Rural Physicians’ Competency With Trauma Care
Advance Trauma Life Support
4
Basic Life Support2 Advanced Cardiac Life Support2 Pediatric Advanced Life Support2 Rural Trauma Team Development4
JOURNAL OF TRAUMA NURSING
TABLE 3
Summary of Crawford’s Recommendations to Enhance Registered Nurse and Physician Communication
1. Respectfully greet each other and introduce new staff members to other care providers 2. Establish a nonhierarchical and collaborative communication structure emphasizing respect, openness, active listening, and a free flow of patient-centered information 3. Use a structured tool, such as situation–background– assessment recommendation, to focus communication on patient care needs 4. Increase opportunities for sharing about the differences between the work of the nurse and the physician, using that knowledge to create a collaborative common ground, meeting patient needs 5. Encourage active participation among the team involving all disciplines in programs such as multidisciplinary rounds or care conferences 6. Nurses should be timely prepared with accurate and relevant patient information when communicating with physicians and other team members. Succinct communication needs to be refined. This is particularly relevant when communicating condition changes and patient care needs over the phone 7. Establish specific procedures to eliminate unnecessary telephone calls, such as bundling redundant phone calls and the development of clinical algorithms when appropriate 8. Implement effective strategies that support chain-ofcommand procedures and enforcement of disruptive behavior policies9
As noted in the sentence immediately preceding, a bright future is forecasted for telemedicine on the basis of the advances in telecommunication networks and concomitant transmission of increasingly high-quality images.
Acknowledgments The authors thank 3 potential reviewers—Kathy Mears, St John Medical Center; Dr Melissa Craft, the University of Oklahoma Health Science Center; Casie Brim, ARNPACNP, St John Medical Center.
REFERENCES
1. Ricci MA, Caputo M, Amour J, et al. Telemedicine reduces discrepancies in rural trauma care. Telemed J E Health. 2003;9(1):3-11. 2. American Heart Association. Basic Life Support, Advanced Cardiac Life Support, Pediatric Life Support. Chicago, IL: ACS; 2013. 3. Emergency Nurses Association. Trauma Nurse Core Course. Chicago, IL: Emergency Nurses Association; 2013.
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4. American College of Surgeons. Advanced Trauma Life Support. Chicago, IL: ACS; 2013. 5. Society of Trauma Nurses. Advanced Trauma Care for Nurses. Lexington, MA: Society of Trauma Nurses; 2011. 6. Schulman CI, Marttos A, Rothenberg P, Augenstein J. Usability of telepresence in a level I trauma center. Telemed E Health. 2013;19(4):248-251. 7. Duchesne JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma. 2008;64(1):92-97. 8. Bjorn P. Rural teletrauma applications, opportunities, and challenges. Adv Emerg Nurs J. 2012;34(3):232-237.
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9. Crawford CL, Omery A, Seago JA. The challenges of nursephysician communication a review of the evidence. J Nurs Adm. 2012;42(12):548-550. 10. Whited JD. Economic analysis of telemedicine and the teledermatology paradigm. Telemed E Health. 2010;16(2):223-228. 11. Federal Grants Wire. Rural Telemedicine Grants. http:// www.federalgrantswire.com/rural-telemedicine-grants.html. Published 201. Accessed May 7, 2013. 12. Heinzelmann PJ, Williams CM, Lugn NE, Kvedar JC. Clinical outcomes associate with telemedicine/telehealth. Telemed E Health. 2005;11(3):329-348.
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Rural Trauma Telemedicine James Bryan Wesson, APRN, CNS-BC ■ Betty Kupperschmidt, EdD, RN, NEA-BC
ABSTRACT Telemedicine is the ability to provide remote health care to patients with the use of a consultant and 2-way interactive technology and telecommunication. Traumatic injuries occurring in rural areas frequently carry a greater risk of mortality than those same injuries occurring in the urban settings. The purpose of this article was to increase practitioner awareness of the potential for improved outcomes as a result of the use of telemedicine in rural trauma care. The use of trauma telemedicine will help decrease the overall mortality and morbidity, length of stay at the urban trauma centers, patient care cost, and transfer time.
Key Words Outcomes, Rural trauma care, Telemedicine
R
ural trauma care is a compelling concern for both authors. One author (BW) works in a large, tertiary facility from which telemedicine consultation is provided for rural trauma patients, whereas the other author (BK) worked for many years as the house supervisor in a rural community hospital. In this capacity, she (BK) had administrative and supervisory oversight of the facility and the emergency room, which meant triaging trauma patients in the absence of physicians and ancillary support. Critically injured patients were stabilized, which might take as long as an hour or more, and transferred to trauma centers approximately 35 to 50 miles away. The question must be asked: If telemedicine consults had been available, would the patient outcomes have been more positive? Currently, many rural practitioners may have limited opportunities to care for major trauma patients compared with colleagues practicing in urban trauma centers.1 For the practitioners, limited opportunities for care provision may
Author Affiliations: St John Health System, University of Oklahoma Health Science Center, Broken Arrow, Oklahoma (Mr Wesson); and University of Oklahoma Health Science Center, Broken Arrow, Oklahoma (Dr Kupperschmidt). The authors declare no conflicts of interest. Correspondence: James Bryan Wesson, APRN, CNS-BC, University of Oklahoma Health Science Center, 2828 North Lions Dr, Broken Arrow, OK 74012 ([email protected]). DOI: 10.1097/JTN.0000000000000012
JOURNAL OF TRAUMA NURSING
result in deceased competency level of skills essential when caring for trauma patients. For the patient, this limited exposure could result in an increased length of stay, morbidity, and costs as well as delays in transfer to tertiary centers. Increasing awareness of various strategies that rural hospital nurses and physicians may incorporate into their practice will lead to evidence-based care in the rural setting with improved patient care outcomes (see Tables 1 and 2).
PURPOSE Some form of telemedicine has been in use since the early 1900s, beginning with the use of 2-way radios and progressing to the use of interactive real-time technology.6 Telemedicine can be extremely beneficial for those individuals living in remote/rural-isolated communities. Use of this technology may provide access to medical care that might not be available to rural patients and provide education for health care practitioners. When rural-dwelling individuals experience major trauma, the community hospital may be unprepared to handle the complex care demanded by the patient’s injuries. This inability to provide the care needed may be the result of the lack of opportunity to care for trauma patients, and thus opportunities to maintain one’s knowledge base and competencies, and not provider incompetence. It is incumbent upon providers to acknowledge their competencies or lack of these essential competencies when caring for the trauma patient. Paramount in these competencies is the ability to quickly assess which patients can be safely managed at the local level and those patients who must be transferred to a trauma center. Physicians and nurses have an ethical obligation to all patients to avoid causing further harm and provide optimal evidence-based trauma care. This care must be provided regardless of race, creed, color, or the ability to pay.
Value of Telemedicine Telemedicine implemented in rural communities has been shown to significantly impact care by decreasing trauma center cost and increasing patient days in community hospitals, and venue for both facilities.7 Telemedicine has the potential to eliminate unnecessary cost and poor patient outcomes incurred when patient transfers to urban centers are delayed. With telemedicine, more severely injured patients are identified quickly and rapidly transferred to trauma centers. The consultant and trauma centers dedicated to caring for critically ill/severely injured WWW.JOURNALOFTRAUMANURSING.COM
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trauma patients can quickly and expertly provide the care demanded by these severely injured patients. Keeping patients who can be safely and expertly cared for at this level in community settings avoids the inconvenience of time away from family members incurred when patients are needlessly transferred to trauma centers. Strategies rural providers can use to facilitate their ability to provide this optimum trauma care are discussed in the next paragraphs.
Telemedicine Telemedicine is an innovative strategy that is currently being used in many situations. Telemedicine refers to use of a consultant based in a trauma center (this center may be in the same state or a different state) that interacts and consults with the rural providers (physicians and registered nurses) via interactive technology. For the purposes of this article, these physicians at trauma centers are referred to as consultants. The consultant may be a board-certified critical care-trained trauma surgeon, a fellow, or a resident, who for the purposes of this article interacts with rural care providers at all stages of patient care (triage to transfer). Establishment of telemedicine systems in rural emergency departments enables primary care providers to receive immediate life-saving advice or instruction from the consultant.8 During the initial assessment phase and resuscitation, the consultant may be able to defer timeconsuming procedures and expedite transfer to the trauma center.8 With telemedicine in place, the consultant is able to answer the staff’s questions and provide immediate feedback from the remote site.6 For example, the consultant may provide support and guidance for airway management, fluid resuscitation, and early administration of blood products and recommended best practice for reversal of therapeutic anticoagulation.8 Telemedicine facilitates a speedy, safe transition from the rural setting to the urban trauma center and avoids untimely delays. At all levels of care, effective communication is an essential prerequisite for safe, effective care. Selected strategies to foster effective communication are discussed in the next paragraph.
Effective Communication Effective communication is a key component of interdisciplinary collaboration and teamwork, and is essential for quality patient care. Regardless of the setting, poor communication undermines a collaborative organizational culture and contributes to increased clinical errors, poor patient outcomes, and provider dissatisfaction. Crawford et al9 proposed strategies to support and facilitate a collegial nurse/physician relationship. These strategies (see Table 3) include treating each other with respect and using a structured tool to focus communication on the patient (such as situation–background–assessment recommendation) and specific procedures to eliminate 200
WWW.JOURNALOFTRAUMANURSING.COM
unnecessary phone calls. When a nonhierarchical and collaborative relationship exists, the main focus becomes the patient. It is essential that interdisciplinary collaboration occur at all levels among staff at each facility. Ineffective communication may jeopardize the ability of the consultant to provide the timely, effective consultation demanded by the patients’ injuries. Thus, all personnel must share one common focus—the patient. As nurses and physicians become increasingly competent with core competencies for effective communication including the suggestions offered by Crawford (Table 3), they will be better able to establish collaborative interprofessional relationships. Two key elements necessary for collaborative cultures are language (how people speak to each other) and behavior (how people treat each other).9
Liability Issues Issues of licensure and other liability issues must be considered. For example, if the consultant is based in another state or country, certification and licensure requirements may vary. Thus, it is crucial that both settings identify and address these requirements to ensure that there are no discrepancies.
Cost Incurred With Implementing and Sustaining Telemedicine Implementing and sustaining telemedicine infrastructure comes at a significant initial cost. A telemedicine system requires hardware, software, and other communication commodities to function.10 Grants are available through the Department of Health and Human Services to provide technical assistance in the development of telehealth services in rural communities.11 These grant funds allow hospitals to either purchase or lease equipment or install equipment and to operate and evaluate the telehealth systems.11 These grants do require quantitative outcome studies to measure the impact on quality of care, the appropriateness of use of the technology, whether care access and clinical outcomes were improved, and the extent to which the cost of service delivery was affected in terms of efficiency and effectiveness of care.11 Cost-effectiveness is based on the concept of incremental costs and/or incremental outcomes.10 Incremental cost refers to the cost difference of telemedicine being implemented versus the alternative of not being implemented.10 An incremental outcome refers to improvement or lack of improvement once telemedicine has been implemented.10 A longitudinal study of 814 trauma patients (pretelemedicine, n = 351; and posttelemedicine, n = 463) was conducted. Pretelemedicine, patients who presented to the local community hospital were evaluated by either a physician or a nurse practitioner. All of these patients were transferred to the trauma center for Volume 20 | Number 4 | October–December 2013
Copyright © 2013 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
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TABLE 1
Resources to Facilitate Rural Registered Nurses’ Competency With Trauma Care
Basic Life Support2 Advanced Cardiac Life Support2 Trauma Nurse Core Course3 Pediatric Advance Life Support2 Rural Trauma Team Development4 Advance Trauma Care for Nurses5
definitive management. Posttelemedicine, trauma patients were seen and telemedicine consults were obtained from the trauma center; of 463 of these patients, 63 (13.6%) of the patients were admitted to the local community hospital, 51 (11%) were transferred to the trauma center, 284 patients were discharged home, 15 patients left against medical advice, a patient died, and a few were transferred to another local community hospital. There was no data reported on 44 patients initially treated at the community hospital. Overall, there was a dramatic decrease in hospital cost. Posttelemedicine, the total cost was $1 126 683 when compared with the pretelemedicine cost of $7 632 624, which represented a significant cost savings of $6 505 941.7
CONCLUSION Implementation of rural trauma telemedicine is decidedly beneficial for nurses and physicians providing trauma care as well as for the recipients of that care. Heinzelmann and colleagues12 conducted a review of clinical outcomes associated with rural telemedicine. Although they decried the dearth of sound methodological research designs, they asserted that their review affirmed the importance of telemedicine. They found that higher levels of care were provided through telemedicine, and in several instances, potential planned transfers were avoided. In addition, these authors forecasted a bright future for telemedicine on the basis of the advances in telecommunication networks and concomitant transmission of increasingly highquality images.
TABLE 2
Resources to Facilitate Rural Physicians’ Competency With Trauma Care
Advance Trauma Life Support
4
Basic Life Support2 Advanced Cardiac Life Support2 Pediatric Advanced Life Support2 Rural Trauma Team Development4
JOURNAL OF TRAUMA NURSING
TABLE 3
Summary of Crawford’s Recommendations to Enhance Registered Nurse and Physician Communication
1. Respectfully greet each other and introduce new staff members to other care providers 2. Establish a nonhierarchical and collaborative communication structure emphasizing respect, openness, active listening, and a free flow of patient-centered information 3. Use a structured tool, such as situation–background– assessment recommendation, to focus communication on patient care needs 4. Increase opportunities for sharing about the differences between the work of the nurse and the physician, using that knowledge to create a collaborative common ground, meeting patient needs 5. Encourage active participation among the team involving all disciplines in programs such as multidisciplinary rounds or care conferences 6. Nurses should be timely prepared with accurate and relevant patient information when communicating with physicians and other team members. Succinct communication needs to be refined. This is particularly relevant when communicating condition changes and patient care needs over the phone 7. Establish specific procedures to eliminate unnecessary telephone calls, such as bundling redundant phone calls and the development of clinical algorithms when appropriate 8. Implement effective strategies that support chain-ofcommand procedures and enforcement of disruptive behavior policies9
As noted in the sentence immediately preceding, a bright future is forecasted for telemedicine on the basis of the advances in telecommunication networks and concomitant transmission of increasingly high-quality images.
Acknowledgments The authors thank 3 potential reviewers—Kathy Mears, St John Medical Center; Dr Melissa Craft, the University of Oklahoma Health Science Center; Casie Brim, ARNPACNP, St John Medical Center.
REFERENCES
1. Ricci MA, Caputo M, Amour J, et al. Telemedicine reduces discrepancies in rural trauma care. Telemed J E Health. 2003;9(1):3-11. 2. American Heart Association. Basic Life Support, Advanced Cardiac Life Support, Pediatric Life Support. Chicago, IL: ACS; 2013. 3. Emergency Nurses Association. Trauma Nurse Core Course. Chicago, IL: Emergency Nurses Association; 2013.
WWW.JOURNALOFTRAUMANURSING.COM
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4. American College of Surgeons. Advanced Trauma Life Support. Chicago, IL: ACS; 2013. 5. Society of Trauma Nurses. Advanced Trauma Care for Nurses. Lexington, MA: Society of Trauma Nurses; 2011. 6. Schulman CI, Marttos A, Rothenberg P, Augenstein J. Usability of telepresence in a level I trauma center. Telemed E Health. 2013;19(4):248-251. 7. Duchesne JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma. 2008;64(1):92-97. 8. Bjorn P. Rural teletrauma applications, opportunities, and challenges. Adv Emerg Nurs J. 2012;34(3):232-237.
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9. Crawford CL, Omery A, Seago JA. The challenges of nursephysician communication a review of the evidence. J Nurs Adm. 2012;42(12):548-550. 10. Whited JD. Economic analysis of telemedicine and the teledermatology paradigm. Telemed E Health. 2010;16(2):223-228. 11. Federal Grants Wire. Rural Telemedicine Grants. http:// www.federalgrantswire.com/rural-telemedicine-grants.html. Published 201. Accessed May 7, 2013. 12. Heinzelmann PJ, Williams CM, Lugn NE, Kvedar JC. Clinical outcomes associate with telemedicine/telehealth. Telemed E Health. 2005;11(3):329-348.
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