Telemedicine for acute plastic surgical trauma and burns

Methods and materials 

A Telemedicine team was created consisting of nursing staff, medical illustrators, audit personnel, Information Technology experts, Consultants and Junior Staff of the surgical specialties based at the QVH (Plastic Surgery and Maxillofacial Surgery). Specialist software was commissioned (DISTAR Telemedicine, Digital Image ST-orage And Retrieval, and TM Client©) to provide secure and technically simple data acquisition and transfer. The software consists of five simple steps for image location, selection of the correct images with a small preview check, demographic data entry, recording the level of consent and transmission of the encrypted email. The average file size was 700KB, for 24-bit colour images at a resolution of 1600×1200pixels. This was manageable for the hospital networks and allowed rapid transmission over the Internet. The encrypted email could be sent from other hospital sites (external) or networked computers within the QVH (internal). Upon arrival at the QVH server (Pentium 4 256MB RAM and RAID-1 mirrored 14GB disks) emails were decrypted and were available for viewing at any networked computer. The hospital computers operated Windows NT and were a minimum of Pentium II, 64 RAM; but most commonly used were Pentium III, 128 RAM. Images were viewed on a screen resolution of 800×600pixels and recorded onto a database, which was backed up daily.

The referring clinicians obtained consent for photographs from their patients and emailed digital images via the NHS intranet, in addition to the usual telephone referral. A plastic surgery trainee (SMJ) was employed to drive the project in the early stages. Over a six-month period the system was introduced to 10 hospitals that regularly referred injuries to QVH. During this six-month period we undertook a 10-week retrospective evaluation study. The Telemedicine team reviewed the initial results, and the installation of the telemedicine software and education programme in referring units was continued.

A subsequent prospective 12-week trial was carried out to investigate changes in patient management from the telemedicine assisted referrals compared to telephone only referrals. From 01 March 2003 to 23 May 2003 the receiving clinician recorded the demographic and clinical details of all trauma referrals. Statistical analysis was performed with the chi squared test and confidence interval calculation.

Results 

Ten-week retrospective evaluation of the telemedicine system 

We received 973 referrals over 10 weeks from 53 different sites. There were 644 male and 329 female patients; 730 adults and 174 children. A wide variety of injuries were assessed (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7). Use of the system was seen to steadily increase over the initial six-month period (Fig. 8). From the sites with the telemedicine installed there were 452 patients referred; telemedicine was used for 42% of these patients. After initial resistance, referring clinicians were generally pleased with the introduction of the system, finding it easy to use and helpful in the referral process. Receiving clinicians also expressed an improvement in the clarity of the information.

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Figure 1 The distribution of injuries and the use of telemedicine during the 10-week evaluation study.

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Figure 2 Radiograph of a crushed finger fracture.

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Figure 3 Clinical image of finger in Fig. 2.

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Figure 4 Flame burn to fingers.

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Figure 5 Flank and buttock post-debridement of necrotising fascitis.

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Figure 6 Paediatric mixed depth burn.

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Figure 7 Pre-tibial laceration.

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Figure 8 The use of telemedicine at the Queen Victoria Hospital since the introduction of the specialist software TM Client© in January 2002.

Twelve-week prospective cohort study 

Over 12 weeks 996 referrals were received from over 60 different sites. There were 607 male and 389 female referrals; 725 were adults and 271 were children. The telemedicine system was available for 389 referrals, and used for 243 referrals (63%). Analysis was undertaken of telemedicine system availability, not only when used, to minimise bias from the referring clinician's choice.

A significant difference was noted (P=0.004) in the management of patients with and without the availability of the telemedicine system (Table 1). Significantly fewer patients needed to come for further assessment or review and more patients could be directly booked for definitive care on an operating list in our Day Surgery Unit (10.5%) when the telemedicine system was available. We also observed a decrease in number of occasions when the QVH was unable to accept a referral due to a lack of capacity. There was no increase or decrease in patients being managed with only telephone advice, nor for patients admitted to their local hospital to await transfer to the QVH (outlier).

Table 1. Difference in the management of referrals with and without telemedicine availability

		Telemedicine assisted referral		Telephone only referral
		% (n=389)	Confidence intervals	% (n=607)	Confidence intervals
	Admit	29.6	(25.2–34.3)	28.3	(24.9–32.0)
	Review	15.4	(12.2–19.3)	22.1	(19.0–25.5)
	Dressing clinic	0.5	(0.1–1.9)	1.2	(0.6–2.4)
	Day surgery	27.5	(23.3–32.1)	17	(14.2–20.2)
	Full – unable to accept	8.7	(6.3–12.0)	12.5	(10.1–15.4)
	Outpatients	7.7	(5.5–10.8)	8.1	(6.2–10.5)
	Outlier	4.6	(2.9–7.2)	4.4	(3.1–6.4)
	Telephone advice	5.7	(3.8–8.4)	5.9	(4.3–8.1)
	Inappropriate referral	0.3	(0.0–1.4)	0.5	(0.2–1.4)
	Total	100		100

Discussion 

Telemedicine is a rapidly growing tool in modern medicine, giving the promise of efficiency and better communication between clinicians.8 Telemedicine systems have proved useful in reducing unnecessary transfers in Neurosurgical emergencies,9 and in reducing mortality, complications and costs in Intensive Care.10 In the UK the national telemedicine database has 260 projects currently listed,11 though only a minority have been reported moving into routine or mainstream use, even with successful pilots. There are numerous barriers to the implementation of telemedicine including limited financial support or reimbursement,12, 13 legal uncertainties14 and an inadequate evidence base.15

Image resolution in telemedicine is crucial. On viewing a series of images of different resolutions clinicians can lose confidence in their diagnosis before they realise that the image resolution has changed.16 Our initial assessment demonstrated that 800×600pixels provided good enough resolution for diagnosis,1 confirming a resolution level shown to be effective for dermatology17 and burn injuries.18 Although this image resolution was adequate, technical difficulties in the viewing of images led us to commission specialist software. This facilitated the ease of loading, sending, reviewing, record keeping and security of images.

There have been feasibility studies assessing the role of telemedicine for wound assessment,19 burn injuries,18, 20 fractures21 and replantations.22 There are no previous studies demonstrating superiority to the traditional telephone referral for acute plastic surgery, nor reporting the routine use of telemedicine in the usual referral process. Our initial results confirmed the feasibility of the telemedicine system for assessing all types of acute plastic surgical referrals, with both referring and receiving clinicians reporting benefits.1

Our results demonstrated significant differences in the management of referrals when the telemedicine system was used (Table 1). Triage of referrals was improved with greater use of day surgery and a decreased need for face-to-face assessment. An audit of London region Hand surgery units (including the QVH) showed that nine departments are working so near to maximum capacity that on 17% of occasions they are unable to accept referrals.6 We observed a decrease in the frequency with which patients were not accepted at the QVH with the use of telemedicine.

The changes observed could be because the telemedicine image provided more objective information to the receiving clinician compared to telephone referrals alone. This may have allowed the receiving clinician with greater confidence in planning the delivery of the surgical service, e.g. to book directly to an urgent day case appointment, a next day clinic review or organise an immediate transfer.

In addition to the improved clarity of communication we also observed improved access, earlier and more frequent senior clinician involvement. We believe this is because the telemedicine system images provide enough information to make some clinical decisions immediately and involve senior clinicians prior to the face-to-face consultation.

The evidence for direct cost savings to the providers of telemedicine is poor.23 Only in a few prison and military populations where the patient transportation costs are high is there evidence of cost savings.24 We found no evidence of cost savings for the QVH trust, and only anecdotal patient cost savings. The capital outlay was significant (£70K) for the installation of the computer network lines, equipment and software. Since inception we have had a single plastic surgery trainee responsible for the project, which has facilitated the coordination of the many clinicians and IT personnel using the system at numerous sites.7 This telemedicine clinician also ensures system availability, guides maintenance and upgrades, and continues the training of staff.

The QVH trust developed a ‘Patient Photographic and Video Recording Policy’; to ensure images recorded complied with the Data Protection Acts (1984 and 1998) and the Computer Misuse Act 1990. This ensured clinicians had clear and legally robust guidelines on digital imaging.25 The telemedicine system was designed with a simple tick box page to confirm consent from the patient without the need for extra paperwork. There is an audit trail for each image. Confidential Patient Information can be protected by either using anonymous data, an approach adopted by the British army,26 or by the use of encryption techniques. We use public–private key encryption to allow secure information transfer. Anonymous data are inappropriate for a network with high volumes of similar referrals, as the risk of confusion is likely to be unacceptably high.

The introduction of telemedicine has led to proven benefits in the management of acute plastic surgery referrals at the QVH. This was achieved by using specially designed software, with integral IT support. Telemedicine may be an important component of the Electronic Patient Record, which is due for implementation within the next few years.