- Limit the number of ambulances to one;
- Restrict the number of medics to a small group;
- Identify a limited number of medical applications to focus the system on;
- Employ only one hospital and be used only in pre-designated area; and,
- Devise a set of metrics to gauge the actual performance of BR Med-Connect.
By equipping only one ambulance, the initial costs were significantly lowered and it became possible to fine-tune the actual arrangement of equipment as changes and improvements were identified in the pilot phase.
Restricting the number of medics made training easier and also helped the selected medics to understand that they were playing a very special and influential role. The medics were invited to be open about their thoughts and feelings about the system. A direct result of this decision was that the medics had a complete understanding of what the system would do, eliminating the “big brother” and “mother may I” concerns medics usually have about telemedicine.
The medical applications considered for initial implementation were STEMI, stroke assessment, trauma, ED overcrowding, disaster response, and, improving inter-facility communications.
Of these applications, the first four were selected for immediate implementation. These combination of well understood and immediate applications (STEMI and trauma assessment), with applications that are somewhat “farther out” (stroke assessment and ED overcrowding) recruited a large and diverse number of stakeholders and challenged the project to solve day-to-day problems and ones that required considerable imagination and innovation. It was decided that the remaining two applications would be implemented when the system was expanded to include other Parish hospitals. Each hospital will come on-line as funding is made available and as the program evolves.
Aside from simplifying training and managerial issues by involving only one hospital and a limited geographic range of operation, the results of the system would be sharply focused and more easily assessed. It also helped to assure that the system would be used only where the communications infrastructure supported it. In addition, developing a set of metrics for something as groundbreaking as EMS telemedicine is essential to determine efficacy, cost effectiveness and effects on patient outcomes. It was recognized that conventional metrics may be difficult to employ when meaningful, but intangible effects are seen and/or where the results are complicated by confounding factors. The issue of metrics is discussed for each selected application.
Discussions with the cardiologists at OLOL quickly revealed that there was an immediate need to improve the speed and reliability of 12-lead report transmission and distribution as well as provide a positive way to associate the report with the patient’s name to avoid any possibility of treating the wrong patient. What also came out of the discussions was a general “feeling” by the cardiologists that they would like to see how the patient initially presents.
Because of the bandwidth and other special communication and information management features available to BR Med-Connect, the problems usually associated with 12-lead report transmission essentially disappeared. Unlike conventional cellular transmissions, broadband wireless and 3G systems are particularly well suited to the relatively small amounts of data that constitute a 12-lead report. In addition, because these systems are not subject to the varying demands of voice traffic, the bandwidth and availability of mesh and 3G systems do not have the performance variability of conventional 2G cellular transmissions. At the receive end, the CAREpoint Workstation provides all the features needed for receiving, displaying, printing and distributing 12-Lead reports.
Lastly, because BR Med-Connect is a true telemedicine system, it has capabilities that allow supplementing the 12-lead report with additional information. Because including the patient’s name with the 12-lead report was a firm requirement of the cardiologists, two methods were provided to do this. For one of these methods, the medic simply speaks the patient’s name into the microphone where the recorded wave file is attached to the 12-lead report. The wave file is played back in the ED where it is permanently added (typed into) to the 12-lead report on the CAREpoint’s keyboard.
The second method allows the medic to type the name on the telemedicine system’s keyboard where it becomes a permanent part of the report. The medics are free to choose either method. These solutions satisfied the cardiologists and they immediately “bought into” the system, providing BR Med-Connect and EMS with important allies.
The metrics for the STEMI application were then identified as the conventional STEMI ones (number of transmissions, transmission time, percent of success, time to balloon, etc.) and with this information an objective comparison of conventional methods versus the effects of BR Med-Connect may be made.
As for the more intangible question of “seeing” the patient, after using the system for a while it became apparent that the ability to “see” the patient as they presented to the medic, as opposed to how the patient presents in the ED or the medic’s verbal description, was of great interest to the ED staff. BR Med-Connect is now in the process of refining its procedures to make better use of the video capability and once this is done, a set of subjective metrics will be devised and applied. These metrics may take the form of a scale of one to 10 for “how much were your actions altered by seeing the patient” and “how did seeing the patient improve you ability to manage pre-hospital care.”
One of the big challenges facing EMS in the coming years is the prehospital response to brain attack (stroke). The American Heart Association has already moved to enhance its stroke-related activities and there is a national movement within EMS to further its stroke assessment activities.
A principle problem for EMS is getting an accurate assessment of the type, time of onset and the degree of severity of the stroke. Much like the STEMI effort this information is needed to insure that the patient goes not necessarily to the nearest facility, but rather to the right facility –one that can provide proper stroke treatment. Several leading stroke experts say that, much as a cardiologist is needed for STEMI assessments, with stroke the involvement of a trained neurologist is equally important.
Because initial assessments are highly visual and subjective, notwithstanding the many technical, medical and operational issues that need to be resolved, this is where the image capabilities of BR Med-Connect may make a difference. Clearly, just as there are cases where these capabilities are not needed, there are those times where EMS telemedicine may play an important role in reducing the morbidity and mortality associated with stroke.
The plan now being developed would employ several different mechanisms for stroke assessment, dependant upon the nature of the communications link. When working in an area with good connectivity, such as within a mesh system, the hospital based physician can interact directly with the distant patient in real time and with high-quality images (high resolution, high frame rate, full color) available at both the patient and physician ends of the system. The assessment would be much like a conventional interfacility telemedicine stroke assessment. Because an experienced neurologist can make an initial assessment in three to five minutes, a telemedicine assessment becomes well worth the time expenditure where a destination decision has to be made. Using moderate-to-good connectivity (3G cellular), the assessment can be conducted with a combination of pre-recorded instructions and imaging techniques that send a high quality image of only the selected portion of the image.
In addition to the technical issues, a range of medical/legal issues, licensure and financial issues similar to those already in place for conventional inter-facility telemedicine have to be worked out. The neurology department and the hospital administration at OLOL are now keenly interested in working on this pioneering method of care.
It is expected that a pilot BR Med-Connect-based prehospital stroke assessment program will take about nine months to develop and will run about a year. During this time, procedures will be refined and data collected. Metrics for pre-hospital stroke assessment will be similar to conventional and well established inter-facility activities.
The use of EMS telemedicine for trauma is controversial and complicated. Without question, EMS personnel are extremely well trained in trauma- related care and, except in rare cases, seldom need the assistance of a distant physician. So what is the role of telemedicine in trauma? Beyond providing help in rare cases, having the ED and trauma staff actually see the patient for themselves as a supplement to the medic’s voice report, may go a long way in insuring proper and efficient ED preparation.
By seeing the patient, ED and trauma staff will be in a far better position to assess the needs of the trauma room and insure that the right specialists are called. Because questions and uncertainty have been removed from ED preparedness activities, specialists are more apt to quickly respond. Similarly, when a specialist is not needed, the ED will be more comfortable in not calling them, saving the hospital money and allowing the specialist to attend to other patients rather than stand around in the trauma room.
In addition, because the trauma surgeon is now able to see the actual mechanism-of-injury, they may be better prepared for the patient’s arrival, and may be able to offer valuable assistance to the medics should it be needed. Because a picture is worth a thousand words this may also allow the medics to focus more on the patient, rather than on trying to describe to what is going on the ED staff.
Whereas metrics for the direct medical benefits of trauma-related EMS telemedicine may be difficult to identify and include so many confounding factors, the effect on trauma room staffing is not. Promptness and efficiencies are easily measured and translated to dollars and cents, something of great interest to cost-conscious hospital administrators.