August 26, 2016

Emergency Room

Immediate access to high-level consultations with specialists
is the key benefit of telemedicine in the ER environment.

  • Telemedicine reduces delays in obtaining necessary consultations, patient admissions, and arranging transfers to other facilities.
  • Before the OffSiteCare telemedicine solution was implemented in the ER, I might have to call six hospitals for a traumatic head injury before I could get through to a specialist, and it was very stressful. Now we have fast, 24/7 access to a committed group of specialists who can make treatment recommendations, or assist in deciding whether a transfer is appropriate.
  • Telemedicine consultations can help to reduce unnecessary transfers, preventing families from experiencing financial and emotional distress.
  • Telemedicine has become a vital part of emergency medicine, and has provided a new tool that enables us to improve quality of care.

Interview with Dr. Jorge Gonzales, former E.R. Director, Palm Drive Hospital

What are the primary benefits of telemedicine in the ER environment?

Immediate access to high-level consultations with specialists—that’s the key. The ER is a time-based environment – it can be quiet, and then overloaded in minutes. When you’re in a dramatically-fluctuating environment, you can’t afford to be bogged down by delays. That’s one of the biggest challenges we face in community/rural hospitals – delays in obtaining necessary consultations, delays in patient admissions, and delays in arranging transfers to other facilities. Telemedicine creates an avenue for us to reduce or eliminate these delays.

Before the OffSiteCare telemedicine solution was implemented in the ER, getting a specialty consultation involved multiple phone calls and lost time. I felt very isolated – I could wind up calling six hospitals for a traumatic head injury before I could get through to a specialist, and it was very stressful. I would do everything I could, but my options were limited. Even transferring a patient to a higher-level acute care facility would take a lot of time. I had to make the calls, and wait for the callbacks before I could get guidance on interim care while we were waiting for the patient to be transferred.

Now we have fast, 24/7 access to a committed group of specialists who are available to make treatment recommendations, or to assist in deciding whether a transfer is appropriate. Telemedicine provides the remote doctors with a visual link to our patients. The system is particularly helpful for admitting physicians, as well as consulting specialists who are asked to see ICU patients under the care of a primary specialist, or hospitalist. Telemedicine has become a vital part of emergency medicine, and has provided a new tool that enables us to improve quality of care.

Tell us about the adoption process at Palm Drive Hospital – was the technology accepted immediately, or was there reluctance?

As soon as I saw the potential I pushed for it to be adopted. The potential for improvement was so great that I felt we needed to try it. However, there was some opposition to the program. For example, some of the doctors felt that the efficacy of treating strokes with tissue Plasminogen Activator (tPA) was not proven, so I had to provide supportive research to overcome their objections. There is going to be resistance to any new technology, and telemedicine is very unique. It’s now been about three years since we started, and it is now viewed as a key aspect to our ER implementation.

In addition to hospitalists and intensivists, who are the specialists that you find yourself consulting most often?

Acute stroke neurologists, pediatric critical care, and urology – those are the big ones. When a code stroke occurs, the emergency room physician calls the stroke team and receives a callback within ten minutes. A consultation occurs to determine the best course of action to take. The specialist has several options: beginning tPA therapy immediately, consulting with the patient through remote telepresence, reviewing diagnostic images, and conferring with onsite physicians and family members to decide on the care to be given. It’s almost as if the stroke team is onsite, and our doctors, patients and their family members perceive it that way.

The pediatric critical care program is not used as widely. Consultations start with a phone call, and if a transfer is needed the patient is flown out by helicopter within 20 minutes. The pediatric critical care is able to evaluate the patient by talking to the ER physician and evaluating test results, and quickly determine whether a transport is appropriate. Getting an immediate response is the key – we used to feel like we were on an island without a lifeline, calling for backup, and now our response time to a pediatric case is very fast. If a child is sick and needs care, you don’t want hours to go by and still be waiting on a bed.

How’s the response time?

It’s excellent. You can’t beat it – it’s like they’re next door.

Can you comment on the viability of telemedicine for pediatric critical care in rural areas where care options are limited, and transfers are upwards of two hours?

In that environment, I would recommend that remote telepresence be used to link the rural facility directly to the critical care specialists at one of the referral centers. They are better able to evaluate patients because of the depth of their experience, whereas the doctors at the remote hospitals do not see anywhere near the same volume of pediatric critical care patients.

This provides several benefits. First, diagnosis and treatment can begin immediately to stabilize the patient (face-to-face via the robot, not by phone), and plans for a transfer can be set in motion when needed. In addition, telemedicine consultations can help to reduce unnecessary transfers, preventing families from experiencing financial and emotional distress. This creates a sense of security at the remote facility — they know that they’re not alone, and that they have backup from the pediatric critical care specialists when it’s needed.

Are there any applications for telemedicine in the ER that have not yet been realized?

Yes. Dermatology would be a good one – a committed dermatologist service that is always available. The service could be extended through a center using a rotation of third- or fourth-year residents, or even a chief resident. Alternatively an attending physician could review the cases, or be available to consult on a particularly challenging case. It would be very helpful to have 24/7 access to this service via the robot.