Telemedicine in acute plastic surgical trauma and burns

BACKGROUND: Telemedicine is a relatively new development within the UK, but is increasingly useful in many areas of medicine including plastic surgery. Plastic surgery centres often work on a hub-and-spoke basis with many district hospitals referring to one tertiary centre. The Queen Victoria Hospital is one such centre receiving calls from more than 28 hospitals in the Southeast of England resulting in approximately 20 referrals a day. OBJECTIVE: A telemedicine system was developed to improve trauma management. This study was designed to establish whether digital images were sufficiently accurate enough to aid decision-making. A store-and-forward telemedicine system was devised and the images of 150 trauma referrals evaluated in terms of injury severity and operative priority by each member of the plastic surgical team. RESULTS: Correlation scores for assessed images were high. Accuracy of "transmitted image" in comparison to injury on examination scored > 97%. Operative priority scores tended to be higher than injury severity. CONCLUSIONS: Telemedicine is an accurate method by which to transfer information on plastic surgical trauma including burns.     

Telemedicine to follow patients in a general surgery department. A randomized controlled trial

BackgroundTelemedicine is becoming more popular in many medical specialties but few studies have been conducted in General Surgery. This study aims to evaluate the feasibility of its introduction in this specialty.MethodsA prospective randomized clinical trial (RCT) was conducted in 200 patients to compare conventional vs telemedicine follow-up in the outpatient clinics. The primary outcome was the feasibility of telemedicine follow-up and the secondary outcomes were its clinical impact and patient satisfaction.ResultsPatients were enrolled between March 2017 and April 2018 and there were no statistically significant differences between the groups’ characteristics. The primary outcome was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003). No differences were found in clinical outcomes (P = 0.832) or patient satisfaction (P = 0.099).ConclusionTelemedicine is a good complementary service to facilitate follow-up management in selected patients from a General Surgery department.     

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.

BACKGROUND: By geographic necessity, rural trauma patients must be initially stabilized at local community hospitals before transfer for definitive care. In this study, it was hypothesized that telemedicine consults with trauma surgeons from a Level I trauma center online while the patient was still in the community hospital ED could positively affect care. METHODS: Four community hospital emergency departments in upstate New York and Vermont were equipped with dual cameras with remote control capability. Three trauma surgeons' homes were wired and equipped with telemedicine systems. Protocols were developed for the initiation of a telemedicine consult. RESULTS: There were 26 telemedicine consults over an 8-month period. The telemedicine population was significantly more severely injured and had a higher mortality than the general trauma population admitted to the Level I trauma center. In two cases, it was felt that the telemedicine consultation was potentially lifesaving. On follow-up, more than 80% of the referring providers felt that the telemedicine consult improved care. CONCLUSION: Telemedicine provides a virtual online trauma surgeon to assist with the resuscitation and stabilization of the major trauma patient in a small community hospital. These preliminary results show a positive impact on rural trauma patient care at the local community hospital.     

Initial plastic surgery experience with the first telemedicine links for the British Forces.

In January 1998, the first telemedicine link for the British Defence Medical Services was established between the British military hospital in Sipovo, Bosnia and the Royal Hospital Haslar, the main triservice hospital in the UK. Further links were established later in the year. These simple links use a high-resolution digital camera, the Olympus C1400L and the C1400XL, to capture still images. These are then transmitted without loss of definition as electronic mail attachments to obtain specialist opinions in plastic surgery as well as in radiology, dermatology, orthopaedics, urology, ophthalmology, general medicine, maxillofacial surgery and pathology. Its use is illustrated by representative case reports from the first 11 referrals from Sipovo and elsewhere to the Plastic Surgery Department at Haslar. This system is suitable for use within both a military and a civilian context, anywhere in the world. It can readily be adapted for use by general practitioners and hospital doctors to facilitate referrals to plastic surgery departments.     

Smart phones make smart referrals: The use of mobile phone technology in burn care – A retrospective case series

Telemedicine using cellular phones allows for real-time consultation of burn patients seen at distant hospitals.

Telemedicina y trabajo inteligente: adaptación al español de las recomendaciones de la Asociación Europea de Urología

IntroductionTelemedicine provides remote clinical support through technology tools. It can facilitate medical care delivery while reducing unnecessary office visits. The COVID-19 outbreak has caused an abrupt change in our daily urological practice, where teleconsultations play a crucial role.ObjectiveTo provide practical recommendations for the effective use of technological tools in telemedicine.Materials and methodsA literature search was conducted on Medline until April 2020. We selected the most relevant articles related to «telemedicine» and «smart working» that could provide valuable information.ResultsTelemedicine refers to the use of electronic information and telecommunication tools to provide remote clinical health care support. Smart working is a working approach that uses new or existing technologies to improve performance. Telemedicine is becoming a useful and fundamental tool during the COVID-19 pandemic and will be even more in the future. It is time for us to officially give telemedicine the place it deserves in clinical practice, and it is our responsibility to adapt and familiarize with all the tools and possible strategies for its optimal implementation. We must guarantee that the quality of care received by patients and perceived by them and their families is of the highest standard.ConclusionsTelemedicine facilitates remote specialized urological clinical support and solves problems caused by limited patient mobility or transfer, reduces unnecessary visits to clinics and is useful to reduce the risk of COVID-19 viral transmission.     

Implementation of telemedicine in the care of patients with aortic dissection

Telemedicine uses telephone-based or any form of digital communication for remote clinical services. It has been a field of interest for the last century, with broader implementation of telemedicine technologies during the last 25 years. The COVID-19 pandemic was an impetus for the adoption of these technologies globally across all health care services, including patient care, surgical practice, and workflow. As part of the patient engagement work in the Aortic Dissection Collaborative, this topic was identified as an important patient-centered research topic. Telemedicine has been adopted increasingly in vascular surgery; however, there is little evidence on appropriate use of these technologies pertaining to treating patients with aortic dissection or aortopathy in general. This landscape review summarizes the uses of telemedicine applications pre and post pandemic in medicine and vascular surgery, with a particular focus on uses in aortopathy. Using common resource databases, we identified articles related to the history of telemedicine, its current utilization, and application to vascular surgery and/or aortopathy. We briefly review the history of telemedicine and illustrate a range of applications in medicine before the pandemic, along with its rapid uptake globally during the COVID-19 pandemic. The enablers and barriers to using telemedicine are explored, although as a whole there is satisfaction with its integration among patients and providers. To address these, we offer recommendations to address future research as it pertains to telemedicine technologies in aortic dissection.     

A Novel Telemedicine System for Care of Statewide Hand Trauma

Background: Telemedicine is an evolving tool to increase patients’ access to subspecialty care. Since 2014, Arkansas has been utilizing telemedicine in the evaluation of patients with hand injuries. The purpose of this study is to assess the effect of this novel telemedicine system for the management of hand trauma on patient transfer. Methods: We reviewed data from the first year of the telemedicine program (2014) and compared it to data from the year prior (2013). Data collection from both years included number of hand consults and need for transfer. From the 2014 data, we also recorded the use of telemedicine, type of transfer, distance of transfer, and time to disposition. Results: During 2013 (pre-telemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) utilizing video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%) while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries (P < .001). Conclusions: The telemedicine program was well utilized and provided patients throughout the state with continuous access to fellowship trained hand surgeons including regions where hand subspecialty care is not available. The program resulted in a significant decrease in the number of hospital transfers for the management of acute hand trauma.     

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.     

Telemedicine Use in Orthopaedic Surgery Varies by Race,Ethnicity, Primary Language,and Insurance Status

BackgroundHealthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities.Questions/purposesAre the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019?MethodsThis was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type.ResultsAfter adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03).ConclusionDespite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters.Level of EvidenceLevel III, therapeutic study.     

A brave new world: telemedicine and the facial plastic surgeon

Telemedicine is defined by the American Medical Association (AMA) as "the provision of health-care consultation and education using telecommunication networks to communicate information." Properly used, telemedicine can provide rapid and easy access to general and specialized medical care. Most telemedical programs have focused on general medical care, but telemedicine can be utilized for subspecialty care. However, technical financial, and legal restrictions must be addressed before more widespread use of telemedicine in facial plastic surgery. This article describes the opportunities and impediments presented to the facial plastic surgeon by telemedicine.     

Teleotolaryngology: a retrospective review at a military tertiary treatment facility.

OBJECTIVE/HYPOTHESIS: The use of real-time telemedicine in providing quality health-care in multiple specialties has been demonstrated in several small studies; however, a review of the literature reveals no large-scale prospective or retrospective telemedicine studies in otolaryngology. The telemedicine office at Naval Medical Center San Diego (NMCSD) acquired a large otolaryngology telemedicine patient database, and this study reviews the otolaryngology telemedicine experience at NMCSD over an 18-month period. STUDY DESIGN: We conducted a retrospective and reviewed new patient consults for the NMCSD otolaryngology telemedicine clinic from April 1, 2001, until November 6, 2002. RESULTS: During the study period, a total of 883 patients received new patient evaluations. Of 883 patients, 568 (64.3%) received a preliminary diagnosis and were treated accordingly. Telemedicine resulted in the avoidance of 22.7% consults. Only 115 (13.0%) of 883 patients required traditional face-to-face otolaryngology consultation. In addition, only 30 (4.3%) of 705 patients who underwent flexible nasopharyngoscopy, otomicroscopy, or nasal endoscopy received incomplete examinations. CONCLUSIONS: Our study demonstrates the ability of telemedicine to function in an general otolaryngology setting.     

Preoperative planning for ear surgery using store-and-forward telemedicine

Objective

To determine if store-and-forward telemedicine can be used to accurately plan ear surgery.

Study Design

Case series with chart review.

Setting

Tertiary care hospital.

Subjects and Methods

Charts were reviewed for elective major ear surgeries resulting from telemedicine referrals during a 13-month period. The store-and-forward telemedicine referrals (electronic consultations) included clinical history, digital images, and audiology data. Consultants reviewed each telemedicine case and documented the recommended surgery and estimated operative time. These charts were matched with patients seen in person during a standard evaluation and had identical surgeries recommended. For the telemedicine evaluation and in-person evaluation groups, the recommended surgeries were compared with actual surgeries performed and the estimated time was compared with the actual operative time.

Results

Forty-five ear surgeries were recommended by the telemedicine evaluation and were matched with 45 surgeries from the standard evaluation and included tympanoplasty with or without canalplasty, mastoidectomy, stapes surgery, and myringoplasty. Telemedicine and in-person evaluation accurately predicted the surgery 89 percent and 84 percent of the time, respectively. The average difference of “actual time” and “estimated time” for the actual surgical procedures performed was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person evaluation group.

Conclusion

Store-and-forward telemedicine is as effective as in-person evaluation for planning elective major ear surgery.     

Telemedicine-based new patient consultations for hernia repair and advanced abdominal wall reconstruction

Hernia - Telemedicine has emerged as a viable option to in-person visits for the evaluation and management of surgical patients. Increased integration of telemedicine has allowed for greater access...     

A review of telemedicine in vascular surgery

Telemedicine refers to the delivery of medical care through telecommunications and has been utilized by many medical specialists. In its basic form, telemedicine can involve the use of a telephone or fax. More advanced forms are the transmission of still images, often referred to as "store-and-forward" technology, or real-time two-way interactive video. The former is possible over existing phone lines or the Internet and has enjoyed success in visually oriented disciplines such as radiology and dermatology. The latter requires high bandwidth communication lines and is therefore considerably more expensive. This article reviews the use of telemedicine as applied specifically to vascular surgery. Initial studies indicate that store-and-forward technology can be used to adequately assess and treat wounds in vascular patients. A recent study reported the use of two-way interactive video for remote assessment of a wide variety of vascular patients. Diagnosis and treatment recommendations by the remote physician were found to be comparable to conventional on-site examinations. Patient satisfaction with the telemedicine examination was noted to be extremely high. In conclusion, telemedicine, although not commonly used in vascular surgery, has the potential of increasing patient access to specialty care, while decreasing patient or physician travel. The use of telemedicine in vascular surgery will likely continue to expand as technology improves and costs decrease.     

Implementation and evaluation of telemedicine in burn care: Study of clinical safety and technical feasibility in a single burn center

ObjectiveThe objective of this study is to review our experience in the implementation of an innovative Telemedicine Platform (the Teleburns Project) for the acute care of burned patients. METHODS: We developed and implemented a Teleburns Platform by the creation of a new medical software and hardware for High Definition medical videoconference, in order to assist distant burned patients. After the establishment of the system and revision of technical requirements, an internal validation of the project was done: we managed 40 consecutive burned patients via telemedicine videoconference within our own Center. Following the internal validation, a pilot test with the Verge de la Cinta Hospital (VCH) – located in Tortosa, 180 km away from Barcelona – was conducted. A prospective review of 43 burn patients participating in tele-encounters was performed. The data collected were: patient and injury demographics, need for transfer to our hospital, need for surgical treatment, complications, readmissions and technical problems.ResultsNo discrepancies were found between remote and face-to-face diagnosis and treatment during internal validation, obtaining a 100% reliability. No technical errors were reported. Concerning the pilot test with the VCH, 43 patients were assessed via telemedicine during a 48-month period. Mean age of the participants was 36.7 (0–85 years). The mean total burn surface area was 3.1% (range 0.5–15%). The more frequently affected areas were head and neck (27 patients) and hands (16 patients). As a result of the 43 televisits, 8 patients (18.6%) were immediately transferred to our Burn Center in Barcelona and 12 patients (27.9%) were asked to come a few days later, to be visited in our Day Care Unit. Thus 23 patients (53.5%) could avoid being transferred to the Burn Center. 5 of them were followed via Teleburns without complications and 17 patients were discharged after the first tele-encounter. All patients discharged presented an uneventful evolution and did not receive further care from our Burn Unit. Technical problems were reported in eleven occasions during this phase, none of which prevented completion of the visits.ConclusionsThe use of Telemedicine for burn assessment can improve the accuracy of burn patients triage, resulting in enhanced resource utilization, time and cost saving for the health system and increased quality of care.     

Psychiatric morbidity in a regional plastic surgery centre--one-year review with a proposed categorisation.

Few studies describe the incidence and nature of psychiatric morbidity in plastic surgery patients. We undertook a review of all referrals from the Plastic Surgery Service to the Psychological Medicine Service over a 1-year period (January-December 2001). Standardised socio-demographic information, nature and cause of injury/defect, surgical intervention, surgical outcome, psychiatric diagnosis and psychiatric follow-up were determined. The majority of patients referred had a significant existing psychiatric illness, had made a suicide/parasuicide attempt, or were burns patients. There was a high rate of referral of plastic surgery inpatients. Liaison with plastic surgery staff to allow rapid identification and early management of psychiatric morbidity is an important role for psychological medicine. We outline a defined categorisation of common contexts in which psychiatric morbidity may present to plastic surgery services.     

Optimization of burn referrals

Introduction

Correct estimation of the severity of burns is important to obtain the right treatment of the patient and to avoid over- and undertriage. In this study we aimed to assess how often the guidelines for referral of burn injured patients are met at the national burn centre (NBC), Denmark.

Methods

We included burn patients referred to the NBC in a three-months period. Patient records were systematically analyzed and compared with the national guidelines for referral of burn injured patients.

Results

A total of 97 burn injured patients were transferred for treatment at the NBC and the most common reason for referral was partial thickness burn exceeding 3% estimated area of burn (55% of the patients) while facial burns (32%) and inhalational injury (25%) were other common reasons. We found that 29 (30%) of the referrals were considered potentially unnecessary according to the guidelines. The overtriage was highest among patients suffering of burns due to scalding and these were mostly children below 2 years of age.

Conclusion

An overtriage of referred burn injured patient was found and 30% of the referred patients were treated as outpatients. A telemedicine solution may be useful in the evaluation of burn injured patients before transfer.