TelehealthEmergencyMedicine
Telehealth in the Emergency Department (ED) is used to facilitate triage, provide specialist care to patients (for example, for stroke assessment and management), read radiology imaging, and help with the clinical assessment and management of traumas, disasters, and mass casualty situations(1)(9).
Contents
Emergency Medicine
Emergency Medicine is the field of medicine dedicated to caring for patients with unforeseen injuries or disease. Patients do not need an appointment to see an Emergency Medicine physician. Emergency Medicine Departments (EDs) can be part of hospitals or might be stand-alone (free-standing), such as urgent cares(1). Emergency Medicine cares for patients of all different injuries and illnesses – from mild sprains and lacerations to cardiac arrests and severe traumas. There are many specialized fields of Emergency Medicine, including ultrasound, Emergency Medical Services (EMS), disaster medicine, hyperbaric medicine, critical care, informatics, education & simulation, and international medicine. Emergency Medicine physicians complete a 3- or 4-year residency following medical school. Many of these physicians also complete fellowship after residency.
Emergency Medicine Operations
Emergency Medicine includes both pre-hospital care (EMS) and ED care of patients. EMS services can be provided through volunteer and career prehospital providers. Many counties have an online medical control system where an operator or paramedic is available to help communicate with on-duty medical control physicians. EMS is also involved in educating the community about what to do when there is a medical emergency. (2)
When patients arrive in the ED, by walking-in or by ambulance, they go through triage. During triage, the patient explains their chief complaint to the triage provider, gets their vitals signs checked, and is assigned an Emergency Severity Index (ESI), which stratifies the patient based on acuity. Many EDs have different zones where patients can be cared for, for example a Fast Track zone that sees low acuity patients, an acute zone that cares for moderate acuity patients, and a critical care zone that cares for high acuity patients.
What is Telehealth?
Telehealth is the use of Information Technology (IT) tools to connect patients and providers to deliver medical care through two-way communication.
There are 3 basic categories(1):
- Asynchronous: where patient data and images are sent to providers; providers then send their assessment back to the patient
- Remote Monitoring: which uses sensors to gather patient information
- Synchronous – uses telecommunication platforms to connect providers and patients in real-time
Telehealth devices
There are many devices that can be used to provide telehealth care. In March 2020, the United States Health and Human Services (HHS) granted a waiver for telehealth, stating “HIPAA-covered health care providers may, in good faith, provide telehealth services to patients using remote communication technologies, such as commonly used apps – including FaceTime, Facebook Messenger, Google Hangouts, Zoom, or Skype – for telehealth services, even if the application does not fully comply with HIPAA rules.”(11) Additionally, there are many other third party telehealth platforms and remote monitoring programs that are available for telecommunication within the ED.
Teletriage
Emergency Departments are often crowded and patients may have to wait hours to see a provider. Quickly and efficiently triaging patients is important to make sure that they are evaluated and routed to the correct zone of the ED based on their acuity. Teletriage is where a provider, who is at a different location, can triage patients through telecommunication.(2)(9) The patient walks into a triage room, is instructed to take their own vitals (or someone helps them), and speaks to the provider through a telehealth device. Teletriage allows providers to efficiently triage many patients, including patients at multiple hospitals, during one shift. Teletriage has been found to decrease time to provider and left without being seen rates.(9)
Telestroke
When patients have a stroke, administering appropriate treatment in a short amount of time is important. Treatments of strokes involves a complex medical decision-making process and there is a 4.5 hour window period from the onset of symptoms to administer t-PA. Additionally, neurologists are not available 24/7 at every hospital.(3) Telestroke involves a board-certified neurologist at a distant location evaluating a patient, through telecommunication technology, and assessing whether the patient has a stroke and recommending a treatment.(4)(7) Some hospitals also have mobile stroke units, which are ambulances with CT Scanners. Using Telestroke, neurologists can assess the patient, view the CT Scan results, and order treatments while the patient is in the ambulance.
Teleradiology
Patients arrive in EDs 24 hours a day, 7 days a week. Many patients get imaging, such as x-rays, CT scans, and MRIs that need to be read emergently by a board certified radiologists. Although many hospitals have in-house radiologists, teleradiology, where radiologists remotely read and report radiologic studies helps improve time to reads. There are also “night-hawks”, who are radiologists who provide immediate diagnostic interpretation during off-hours.(5)
Teletrauma
In Emergency Medicine, a wide variety of trauma is seen – from minor wounds to major blunt and penetrating traumas. Some patients might need to be intubated, need needle decompressions and/or chest tubes, require central lines/arterial lines, or need an ED thoracotomy. Some patients might need to be transferred from a rural ED to a level-1 trauma center. With teletrauma, trauma specialists can use telecommunication devices to help provide clinical assessments and plans for traumas, disasters, and mass casualty situations.(6) They can also help guide on-site providers how to perform certain procedures and guide which patients need to be transferred to a different hospital.(8)
References
2. Bashford C, Veenema M. Tele-collaboration in EMS communications: new concepts & technology challenge EMS systems to think outside the box for communications. JEMS. 2002 Oct;27(10):82-6. PMID: 12368769.
3. Blech B, O'Carroll CB, Zhang N, Demaerschalk BM. Telestroke Program Participation and Improvement in Door-To-Needle Times. Telemed J E Health. 2020 Apr;26(4):406-410. doi: 10.1089/tmj.2018.0336. Epub 2019 Jul 9. PMID: 31287782.
4. Reddy ST, Savitz SI, Friedman E, Arevalo O, Zhang J, Ankrom C, Trevino A, Wu TC. Patients transferred within a telestroke network for large-vessel occlusion. J Telemed Telecare. 2020 Sep 20:1357633X20957894. doi: 10.1177/1357633X20957894. Epub ahead of print. PMID: 32954941.
5. Steinbrook R. The age of teleradiology. N Engl J Med. 2007 Jul 5;357(1):5-7. doi: 10.1056/NEJMp078059. PMID: 17611203.
6. Ward MM, Carter KD, Ullrich F, Merchant KAS, Natafgi N, Zhu X, Weigel P, Heppner S, Mohr NM. Averted Transfers in Rural Emergency Departments Using Telemedicine: Rates and Costs Across Six Networks. Telemed J E Health. 2020 Aug 24. doi: 10.1089/tmj.2020.0080. Epub ahead of print. PMID: 32835620.
7. Adcock AK, Choi J, Alvi M, Murray A, Seachrist E, Smith M, Findley S. Expanding Acute Stroke Care in Rural America: A Model for Statewide Success. Telemed J E Health. 2020 Jul;26(7):865-871. doi: 10.1089/tmj.2019.0087. Epub 2019 Oct 9. PMID: 31596679; PMCID: PMC7370840.
8. Latifi R, Weinstein RS, Porter JM, Ziemba M, Judkins D, Ridings D, Nassi R, Valenzuela T, Holcomb M, Leyva F. Telemedicine and telepresence for trauma and emergency care management. Scand J Surg. 2007;96(4):281-9. doi: 10.1177/145749690709600404. PMID: 18265854.
9. Frid AS, Ratti MFG, Pedretti A, Valinoti M, Martínez B, Sommer J, Luna D, Plazzotta F. Teletriage Pilot Study (Strategy for Unscheduled Teleconsultations): Results, Patient Acceptance and Satisfaction. Stud Health Technol Inform. 2020 Jun 16;270:776-780. doi: 10.3233/SHTI200266. PMID: 32570488.
Submitted by Samita Heslin
