1
A Multidisciplinary Teletrauma Program:
Connecting Regional Level I Trauma Expertise
To Community and Rural Hospitals
Jenna Barber
James Murray
Ruchi Thanawala
Northwestern University
MED-INF 498: Capstone Project
June 4, 2014
Table of Contents
Sections
Executive Summary3
Use Case4
Pre-Teletrauma System4 Post-Teletrauma System 5
Background6
Benefits8
Access to Specialists8
Evidence-based Resource Allocation9
Knowledge Sharing10
Challenges10
Experimental Technological Base10
Liability and Privileging11
Economic Sustainability11
Integration Across Different HIT Systems12
Varying Levels of Clinical Expertise & Resources12
Legal and Ethical Issues with Plans for Compliance13
Physician Licensing13
Credentials and Privileges14
Electronic Prescribing14
Informed Consent15
Malpractice Liability16
Standards17
Background17
Types of Services17
Critical Components and Standards18
Relevance of Standards20
Technical Requirements20
Data Flow21
Integration Elements23
HL-7 Message Types24
Connectivity24
Projected Development and Implementation Costs25
Training Requirements25
Multidisciplinary Team25
Technology Training27
Clinical and Communications Training28
Simulation Training Sessions29
Implementation Plan, Workflow, Organization, and Governance31
Project Phases32
Workflow33
Critical Evaluation of Teletrauma System33
Summary 36
References37
Figures and Tables
Figure 1: Teletrauma project participants4
Figure 2: HL-7 Messaging Standard21
Figure 3: Mysis Data Transmission22
Figure 4: View Clinical Data Screen22
Figure 5: Clinical Data Points23
Figure 6: HL-7 Patient Data 24
Figure 7: Operational Costs25
Figure 8: Trauma Workflow26
Figure 9: Teletrauma Display30
Figure 10: Implementation Team31
Figure 11: Project Phases31
Figure 12: Performance Measures35
Table 1: Clinical Quality Measures35
Appendices
Appendix I: Trauma Center Level Designations40
Appendix II: Trauma Team Activation Criteria41
Executive Summary
Premier Health Center (PHC) is a 720-bed, 57 bassinet, Level I trauma center (see Appendix I), tertiary care center located in Johnson City, MA with a population of 153,552 people. PHC is also an academic teaching hospital with fourteen residency and training programs for physicians, physician assistants, and nurses. The catchment area for PHC is approximately 1,000,000. PHC is a member of the larger health system, Premier Health System, and serves as its flagship hospital. Two smaller community hospitals are part of the Premier Health System. Assent Hospital (AH) is 90-bed hospital, Level II trauma center and is located 20 miles from PHC. Community Care Center (CCC) is a 25-bed hospital, Level IV trauma center and is located 25 miles from PHC. In addition to these small community hospitals, three non-affiliated rural hospitals fall within PHC’s catchment area. Rural Hospital A (RHA), Rural Hospital B (RHB), Rural Hospital C (RHC) are 125-bed or less hospitals, and Level III and IV trauma centers.
The objective stands at establishing a multidisciplinary, telemedicine trauma management program connecting the affiliated hospitals, AH and CCC, the non-affiliated rural hospitals, RHA, RHB, and RHC, to the dedicated trauma center in the region, PHC. This telemedicine and telepresence system aims to bring real-time access to trauma management specialists to the affiliated and non-affiliated hospitals outlined. The projected benefits are improvements in morbidity and mortality associated with trauma management directed at lower level trauma centers and patient transfers between hospitals, reductions in length of hospitalization, variations in care, and improvements in the quality of care delivery overall.
Figure 1.
Use Case
Pre-Teletrauma System
SN is a 77-year-old male who presents via ambulance to Community Care Hospital at 2030 hours following injuries sustained when he was hit by a motor vehicle while he was crossing a residential street. He remains confused and hypotensive (low blood pressure) after 5 minutes of loss of consciousness. Additionally, he has facial injuries along with bruising on the chest, abdomen, and pelvis.
The general surgeon on-call is on his way to the hospital. The ED physician and her team have started the trauma protocol to stabilize SN. His airway is intact at the moment but he breathing is labored with decreased breath sounds over the left chest. This indicates a likely pneumothorax (lung puncture and deflation). They put him on high-flow oxygen. A chest tube is warranted immediately. The ED physician has not placed a chest tube for many years but the patient is deteriorating. The physician places a chest tube in the left chest successfully. The patient immediately desaturates (low oxygen levels) and the nurse at the patient’s head notes that she is unable to ventilate him. A surgical airway is required. The facial injuries have caused the patient’s airway to be compromised.
The patient soon goes into cardiac arrest and is pronounced dead at 2130 after many implementation of the advanced cardiac life support protocol.
Post-Teletrauma System
SN is a 77-year-old male who is en route via ambulance to CCC at 2015 hours following injuries sustained when he was hit by a motor vehicle while he was crossing a residential street. While en-route to CCC, the PHC teletrauma surgeon, Dr. Smith, has viewed the patient and discussed his status with the EMTs via the ambulanced-based video communication system. They have determined that the patient likely has a left sided pneumothorax based on the decreased breath sounds the EMTs described. Dr. Smith has recommended that SN be stabilized at CCC with airway evaluation and chest tube placement and then considered for transfer to PHC.The CCC ED physician, Dr. Carter, has been informed of the patient and the evaluation by Dr. Smith. The teletrauma system encounter is started. Dr. Carter and Dr. Smith discuss the patient over the videoconferencing function as they await his arrival at CCC ED. The team has pulled the appropriately sized chest tube and a surgical airway kit.
It has been a few years since Dr. Carter has put in a chest tube, but the recent skills sessions lead by the teletrauma team at PHC have helped her to feel more confident about putting in the chest tube. Dr. Smith reviews the steps briefly. Most important is the possible need for a surgical airway if SN cannot maintain his airway and Dr. Carter cannot place an endotracheal tube. Dr. Smith talks Dr. Carter through the surgical airway as well.
SN arrives at 2030. He remains confused and hypotensive (low blood pressure) after 5 minutes of loss of consciousness. His has facial injuries along with bruising on the chest, abdomen, and pelvis are obvious. Immediately, Dr. Smith uses the video camera, which he can control at the PHC teletrauma station, to view the patient’s face and body. The team at CCC is moving quickly to put the patient on the monitor while evaluating his airway. Dr. Smith sees the data on the monitor immediately. Another team member at CCC is opening up the chest tube kit. Dr. Smith and Dr. Carter note the labored breathing and gurgling sounds from SN’s airway. They decide to attempt an oral intubation (breathing tube in throat), but Dr. Carter cannot see past the large amounts of blood. Dr. Smith and Dr. Carter promptly decide upon a surgical airway. Dr. Carter uses the scalpel to incise the skin over the trachea as Dr. Smith looks on via the teletrauma video communication system. Dr. Smith’s voice is transmitted over speakers throughout the trauma room. He guides Dr. Carter through the process. A surgical airway is successfully placed less than 2 minutes later.
SN is now oxygenating well. A chest tube has also been placed successfully and attention is now turned to the abdominal and pelvis injuries. Dr. Smith and Dr. Carter decide to transfer the patient to PHC for further evaluation and management of a pelvic fracture.
Background
Health care delivery in the modern era is marked with resources extending beyond the four walls of a single hospital. Advances in technology and communications have supported the electronic exchange of data across geographical locations. Some examples include medical data through health information exchanges and voice data over voice-over-IP applications. The use of communications technologies for telemedicine have been in place since the 1900s with two-way radios (Wesson & Kupperschmidt, 2013). In 1978, Dr. R. Adams Cowley demonstrated the use of telemedicine for trauma resuscitation in real time for a staged disaster exercise at Friendship Airport. He used an old satellite technology for the data transfer (R. Latifi, Ong, Peck, Porter, & Williams, 2005).
In the United States and similarly in other countries, the majority of specialized trauma centers and specialists in trauma management are based in urban settings. This framework leaves rural areas vulnerable to the management of severe traumas without adequate and timely access to resources (R. Latifi et al., 2005; Wesson & Kupperschmidt, 2013). In fact, while only a quarter of the population in the US lives in rural regions, 56.9% of mortalities due to motor vehicle collisions occur here. When patients are matched by severity score of injury, those who are treated in rural regions have twice the mortality rate (R. Latifi et al., 2005).
Reasons for the vast discrepancy in mortality rates between urban settings with immediate trauma management capabilities and rural settings include lack of timely access to the subspecialty, adjunctive care (neurosurgery, orthopedics, vascular, cardiothoracic, trauma surgery) needed in comprehensive trauma care(R. Latifi et al., 2005). Additionally, with infrequent exposure to injuries requiring activation of trauma management protocols, the rural health care providers often lack the competencies to manage these injuries. The lack of adept knowledge and resources in trauma management can result in higher patient morbidity and mortality, length of hospitalizations, patient care costs, and transfers to other hospitals(Wesson & Kupperschmidt, 2013). Currently, most rural health care providers and trauma specialists in dedicated trauma centers rely on phone communication to assess and determine the plan of care for a patient suffering from traumatic injuries. The trauma specialists must rely on the assessment of the rural health care provider to determine whether the patient should be transferred to the dedicated trauma center, managed locally, and/or suggest a plan of action (Wesson & Kupperschmidt, 2013).
In an era where we are gathering and have access to vast amounts of data which support clinical decision making (human-based and computerized), telemedicine and telepresence modalities should be used to connect rural health care settings with dedicated trauma centers in the management of traumatic injuries. This potential power of this interconnected web of healthcare providers with immediate access to each other, supplemented with innovative methods to share data surrounding patients such as shared cardiac monitors, radiology image viewing applications, and laboratory values could make the absence of telemedicine in trauma management seem arcane in the next few decades.
Benefits
Access to Specialists
Trauma management is principled on care provided in the “golden hour”, which is the hour during which rapid trauma assessment and resuscitation of the patient reduces mortality. Trauma deaths fall into a trimodal distribution. The first group dies from injuries usually on-scene of the event within seconds to minutes. The second group dies within minutes to hours following the traumatic event. Lastly, the third group will suffer death many days to weeks following injury (Zunder, n.d.). The proposed teletrauma project targets the management of patients in the second group who may present to rural and community hospitals. Transferring the patient, once at a rural facility, often consumes valuable time that may be better dedicated to management of the traumatic injuries.
A real-time teletrauma management system connecting PHC to the aforementioned affiliated and non-affiliated hospitals would provide these hospitals with the support and knowledge of specialists who are off-site. Comprehensive trauma management is a multidisciplinary process. The health care providers engaged in this process include trauma/critical care surgeons, trauma nurses, anesthesiologists, neurosurgeons, orthopedic surgeons, vascular surgeons, plastic surgeons, and radiologists. These individuals are essential to the immediate assessment of a trauma victim, management, and subsequent treatment plan development. Through our teletrauma program, they are theoretically able to participate in all aspects of this trauma protocol remotely in collaboration with the on-site team at the rural or community hospital. The utilization of existing infrastructure and technology, acquisition of and innovation on new technologies, along with process development will be necessary to realize the full potential of the multidisciplinary teletrauma program.
Evidence-based Resource Allocation
Health care resources are finite in availability. With the rising cost of health care, cost consciousness is a guiding principle in the delivery process high quality patient care. The trauma bay is stocked with many resources such as cardiac monitors, airway equipment, radiology equipment such as ultrasounds, intravenous fluids and blood products, and surgical kits for the placement of chest tubes, central venous catheters, open the chest. At times, in addition to the trauma team, specialists such as anesthesiologist, obstetricians, and neurosurgeons may be called in before the patient arrives. A level 1 trauma activation (see Appendix II) can cost approximately $5,000 (Rifat Latifi, 2013). A call from the transferring hospital or emergency medical technicians (EMTs) may suggest that immediate stabilization of injuries associated with those specialties is required.
Teletrauma connecting PHC to the smaller affiliated and non-affiliated surrounding hospitals could help provide PHC important information on the resources immediately required upon patient arrival into the trauma bay. Tailoring the equipment and specialists made available for immediate use based on solid evidence could reduce medical waste in the form of physical items and clinician time. Telephonic transfer consultations between the other hospitals and PHC can be supplemented with direct video feed of the patient during the primary and secondary survey of injuries, sharing of available radiographs and laboratory values, and real-time, two-way communication during the process (R. Latifi et al., 2005).
Extending the teletrauma program to ambulances transporting patients from the site of injury and between hospitals in the PHC catchment should be a future consideration of significant benefit. With the new availability of wireless infrastructure in the catchment area, a program similar to that rolled in the city of Tucson can be considered in Johnson City, MA. University Medical Center (UMC) and the Tucson Fire Department deployed an ER-link system in 2007. This system allows the ED physicians at UMC to see the patient in 20- to 30- second video “snap shots” while the ambulance was stationary and while in motion. This video data has helped the receiving physicians at UMC anticipate the state of the patient when he patient arrives in the ED or trauma bay. Their system includes a camera that can be moved and zoomed within a fixed range for improved visualization of the patient by the physician. Additionally, 12-lead electrocardiogram data is also shared with UMC. Plans are underway to provide hand-held cameras to allow for transmission of specific video feeds not within view of the stationary camera (Rifat Latifi, 2013).
Using all the data available to optimize a patient’s outcomes and the responsible allocation of healthcare resources are core goals in today’s health care delivery system and the proposed teletrauma system. PHC can move to the forefront of innovation and quality of healthcare by using teletrauma to connect PHC will the local, smaller hospitals. Additionally, a future phase of the project should include provisioning ambulances with video and communications equipment to allow for a virtual physician to enter the ambulance with the highly qualified EMTs(Rifat Latifi, 2013).
Knowledge Sharing
A teletrauma system, bridging the gap between rural and community hospitals and PHC, can lead to effective dissemination of trauma management knowledge. Learning in the active clinical environment is the long held practice in medical training. Consistent and reliable access to knowledgeable educators can influence the delivery of care in time-sensitive situations such as acute trauma. As collaboration in the management of these patients increases through the teletrauma system, the rural and community hospital physician will likely feel more comfortable and confident in administering varying degrees of care at their own facility. Using the teletrauma system for training mock trauma scenarios can create ease of use with the system for all parties, provide education in a safe, simulated environment, and identify areas for improvement (knowledge, process, system) outside of the real-life setting.
Challenges
Experimental Technological Base
Many challenges in the implementation of teletrauma are centered on the different technologies upon which the system can be based. Since telemedicine is a developing field, all of the implementations are in some experimental phase. Without a strong model with a lengthy history upon which to develop our teletrauma system, we anticipate challenges requiring innovative thinking to arrive at solutions. Existing telemedicine programs have used dedicated T1 lines, integrated services digital network (ISDN), Internet protocol (IP) technology, or even satellites for connectivity(R. Latifi et al., 2005). A broad analysis of current implementation of technologies for telemedicine and new approaches will guide the development of the teletrauma program connecting PHC to the rural and community hospitals locally.
Liability and Privileging
Health care provider licensure is provided by individual states. While PHC and the affiliated community hospitals are all within Massachusetts along with Rural Hospital A, Rural Hospital B and Rural Hospital C are in Connecticut. PHC’s location near the border between Massachusetts and Connecticut presents a unique challenge with licensure considerations in the teletrauma program. The requirement to obtain licensure in Connecticut for all the physicians who may be engaged in the acute management of a trauma patient through the teletrauma system could be difficult. Similarly, all the participating hospitals must agree on the privileging policies for the teletrauma physicians(Wesson & Kupperschmidt, 2013). As this is a multidisciplinary project, the physicians that will require coverage for licensure and privileges span many departments (trauma surgery, radiology, orthopedic surgery, neurosurgery, critical care, etc.). The presence of clear processes to manage these issues is necessary to protect the hospitals, physicians, and patients medico-legally.