Obstacles and Solutions Driving the Development of a National Teleradiology Network

Background: Teleradiology has the potential to link medical experts and specialties despite geographical separation. In a project report about hospital-based teleradiology, the significance of technical and human factors during the implementation and growth of a teleradiology network are explored. Evaluation: The article identifies major obstacles during the implementation and growth of the teleradiology network of the Berlin Trauma Hospital (BG Unfallkrankenhaus Berlin) between 2004 and 2020 in semi-structured interviews with senior staff members. Quantitative analysis of examination numbers, patient numbers, and profits relates the efforts of the staff members to the monetary benefits and success of the network. Identification of qualitative and quantitative factors for success: Soft and hard facilitators and solutions driving the development of the national teleradiology network are identified. Obstacles were often solved by technical innovations, but the time span between required personal efforts, endurance, and flexibility of local and external team members. The article describes innovations driven by teleradiology and hints at the impact of teleradiology on modern medical care by relating the expansion of the teleradiology network to patient transfers and profits. Conclusion: In addition to technical improvements, interpersonal collaborations were key to the success of the teleradiology network of the Berlin Trauma Hospital and remained a unique feature and selling point of this teleradiology network.

The relative importance of clinical factors in initiating interfacility transfer of major trauma patients: A discrete choice experiment

Introduction and Objectives Approximately 30% of patients meeting severe injury criteria are never transferred to lead trauma centers (LTCs). The reasons for this gap are not fully understood but involve both system-level factors and individual decision-making. We used a method called discrete choice modeling (DCM) to evaluate which clinical and demographic patient factors might make emergency physicians more likely to initiate transfers to LTCs. Methods An email survey was distributed to physicians working in emergency departments (EDs) in Ontario. The relative importance of clinical and demographic patient attributes as drivers for transfer was evaluated using DCM. Simulated patient cases were created using a random generator to combine attributes. Each respondent was presented with 36 different patients in sets of three and asked if they would transfer each patient to an LTC. The relative importance of each driver was then compared across physician characteristics. Results One hundred and fifty three emergency physicians completed the survey. The drivers for transfer, expressed as utility scores, were derangements in hemodynamics (22), CNS/head injuries (19), pelvic fractures (11), chest injuries (10), comorbidities (9), abdominal injuries (8), extremity injuries (7), mechanism of injury (7), age (5), and gender (2). Drivers for patient transfer did not differ based on physician experience or type of training. Conclusion In this DCM study, the clinical and demographic factors most likely to make emergency physicians consider patient transfers to LTCs were patient hemodynamic derangements and CNS/head injuries. Overall, these drivers did not differ by physician experience or training. An understanding of such patient-level drivers for transfers to LTCs may improve the implementation of evidence-based interfacility transfer criteria.

Telemedicine in the Surgical Disciplines

In acute care surgery, regional trauma centers and the American College of Surgeons Committee of Trauma (COT) have worked to address the fundamental challenge of patient stabilization at remote referring facilities, followed by timely patient transfers. However, limitations with patient transport still exist because of adverse weather and lack of emergency vehicles or logistics for emergent transport, demanding ongoing patient care at the originating site. Integration of telemedicine protocols in regional trauma systems has been shown to be effective in facilitating appropriate and timely patient transfers and helps improve the efficacy of resuscitative care in critical-access facilities. Telemedicine has also been shown to be an effective means of service delivery for preoperative, operative and postoperative consultations, reducing time and cost barriers for patients living in remote areas and improving adherence to treatment plans. This increased continuity of care promotes positive outcomes and reduces preventable hospital admissions. Telemedicine also plays a role in surgical education, preceptorship, and mentorship, as well as continuing medical education and multidisciplinary conferences.

Emergency Ocular Telehealth Services

The availability of ocular telehealth services in the emergency department and urgent care center settings can facilitate the diagnosis and management of ocular complaints. While the start-up costs involving ophthalmic equipment and training modules may seem high, it is well worth the investment knowing that these services will increase patient satisfaction, improve overall clinical outcomes, and aid in the physician decision-making process in regard to patient transfers for eye emergencies. Although the majority of ophthalmic urgencies can be managed as outpatient, true ophthalmic emergencies may require more immediate evaluation in order to preserve good visual outcome. Gaps in the availability of ophthalmologists needed for the immediate evaluation of eye emergencies can be filled by the implementation of ocular telehealth.

Exploring Pharmacy Trainee Experiential Learning in a Full Scope Collaborative Rural Primary Care Practice: A Retrospective Chart Review

Despite reported benefits of pharmacy trainees (e.g., pharmacy students, pharmacy residents) in hospital settings, limited research on the impact of these trainees has been conducted in rural primary care. To explore the potential benefits and impact of pharmacy trainees practicing in a supervised collaborative rural primary care setting, a retrospective chart review was conducted. Drug therapy problems (DTPs) were classified using the Pharmaceutical Care Network Europe (PCNE V9) system. Valuation was measured using a validated tool developed by Overhage and Lukes (1999). Over 16 weeks on a part-time basis, pharmacy trainees (n = 3) identified 366 DTPs during 153 patient encounters. The most common causes for DTPs were related to patient transfers and the need for education. Drug level interventions carried out directly by trainees under supervision accounted for 13.1% of total interventions. Interventions that required prescriber authorization had an acceptance rate of 83.25% higher than previous acceptance rates found in urban primary care settings. About half (51%) of the interventions proposed and made by pharmacy trainees were classified as significant or very significant, suggesting these trainees added significant value to the pharmacy service provided to rural community residents. This study suggests that pharmacy trainees can be effective resources and contribute meaningfully to patient care in a collaborative rural primary care team setting.

Unplanned Transfers From Intermediate Care Units to Intensive Care Units: A Cohort Study

This study evaluated unplanned transfers from the intermediate care unit (IMCU) to the intensive care unit (ICU) among urgent admissions. This retrospective, observational study was conducted in 2 ICUs and 1 IMCU. Three patterns of urgent admission were assessed: admissions to the ICU only, admissions to the IMCU only, and admissions to the IMCU with subsequent transfer to the ICU. Of 5296 admissions analyzed, 1396 patients (26.4%) were initially admitted to the IMCU. Of these, 172 (12.3%) were transferred from the IMCU to the ICU. Mortality was higher in patients transferred from the IMCU to the ICU than in the 3900 ICU-only patients (odds ratio, 3.22; 95% CI, 1.52-6.80). Most transfers from the IMCU to the ICU (135; 78.5%) were due to deterioration of the condition for which the patient was admitted. Patient transfers from the IMCU to the ICU were common, were associated with increased hospital mortality, and were mostly due to deterioration in the condition that was the reason for admission.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient’s physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard ‘run chart rules’ to detect changes in outcomes over time and Welch’s t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Biomechanical Evaluation of Back-Support Exoskeletons during Patient Transfers

The purpose of this study was to investigate the effects of three back-support exoskeletons (FLx ErgoSkeleton, V22 ErgoSkeleton, Laevo V2.5) and patient transfer methods (Squat pivot, stand pivot, scoot) on the musculoskeletal loading and self-reported usability measures during patient transfers between a bed and a wheelchair. In a repeated-measures laboratory study, 20 experienced caregivers (17 females and 3 males) performed a series of 24 bed-to-wheelchair transfer tasks (2 directions × 4 exoskeleton conditions × 3 patient transfer methods). The trunk flexion and lateral flexion angles, bilateral hand pull forces, and muscle activities of the erector spinae were significantly different by exoskeleton conditions and patient transfer methods (p’s < 0.01). The usability measures were significantly affected by exoskeleton designs (p’s < 0.01). There were significant two-way interaction effects on the trunk flexion and lateral flexion angles and muscle activities of the erector spinae (p’s < 0.01). For the squat pivot method, three back-support exoskeletons showed the largest reduction of erector spinae muscle activities (47.4 to 83.5% reference voluntary contractions) compared to no exoskeleton. This indicated the effects of exoskeleton conditions on the trunk postures and erector spinae muscle activities depended on the patient transfer method. More research could be needed to improve the trunk postures and usability of back-support exoskeletons suitable for patient handling.