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Emergency telemedicine
Over recent decades, the field of telemedicine has been witness to periods of great promise, relative stasis as well as overstretch and false starts.
However, there is one telemedicine application which has seen steady, consistent growth. This is emergency telemedicine, where application development, especially teleconsultation and teleradiology, has synchronized with increasing demand for A&E as well as the forward march of telecoms technology.
From the outset, the benefits of telemedicine were self-evident in emergency care in settings such as ski resorts, highway or rail accidents, and after natural disasters. Telemedicine enabled trauma specialists to interact with overtaxed field personnel on site, to gauge the severity of injuries and provide clinical assessments on treatment or evacuation. This aspect of telemedicine was spun out off one of its first movers, the military.
Telemedicine and travel
The roots of ‘serious’ telemedicine practice can be considered to date to the 1990s. Nevertheless, medical practitioners were aware of the enormous possibilities it afforded well before this.
In the 1930s, luxury liners used marine radio-telephones to communicate with physicians about urgent cases on board. Travellers were again the core target market for the first teleradiology consultations, conducted in the 1960s by Dr. Kenneth Bird, who used a two-way/interactive television system that connected Massachusetts General Hospital to Boston’s Logan Airport to provide emergency medical care.
1994: A&E referrals fall at Belfast hospital
Among the earliest case studies on modern emergency telemedicine is a 12-month review of a 1994 link between the Royal Victoria Hospital in Belfast and a minor treatment centre (MTC) in South Westminster, London. Over the study period, the telemedicine link was actively used in only about 0.5% of cases. However, the number of patients referred to a GP fell dramatically as did those referred to A&E. Another interesting observation was an increase in confidence of the nursing staff at the Westminster MTC.
Wembley study compares outcomes, radiologists vs. teleradiologists
At the beginning of 1996, Wembley Community Hospital in London established a minor accident treatment service (MATS), supported by an advanced telemedical link to Central Middlesex Hospital. The system was run by emergency nurse practitioners based on a set of clinical protocols which consisted of prompts advising the use of telemedicine.
Two years later, a paper evaluated six months activity at the MATS, covering all patients seen – a total of 2,843, with 150 teleconsultations. After an interval of three months, 99 per cent of telemedical and 95 percent of non-telemedical cases were followed up. Interestingly, while no further problems had arisen with the telemedical group, 26 of the non-telemedicine group had consulted their GP for the same problem. Another interesting finding was that A&E teleconsultants interpreting radiographs performed better than the consultant radiologist who subsequently interpreted the original films.
Head CT scans
Similar efforts were also made in the US and continental Europe. Other than minor injuries support, another application area with near-universal acceptance in A&E practice consisted of the transmission of head CT scans to a tertiary neurosurgical centre, in order to obtain an immediate expert opinion.
Economic impact of emergency telemedicine
By the late 1990s, rather than convenience alone, the first arguments about the economic impact of emergency telemedicine had begun to appear. A 1997 paper from Hong Kong found a significant reduction in unnecessary transfers, alongside a decrease in adverse events occurring during transfer. Another study from Austria during the same year concluded that though teleradiology for CT scans was more expensive than transferring the physical scans by taxi, it was considerably quicker, and much less expensive than transferring the patient.
Growing ER costs drive US interest in telemedicine
The acceleration of growth in mobile telecoms quality onwards from the late 2000s, along with sharp falls in cost, has intensified the case for emergency telemedicine. Alongside, increased demographic pressure on emergency rooms due to an ageing population and ER staff shortfalls have strengthened this further.
ER figures have been used to make the case for emergency telemedicine in the US. 130 million people visit ERs each year, up 36 percent from 97 million in 1995. In spite of this, the number of ERs in the US dropped by 11 percent over the period.
One leading healthcare provider, Cardinal Health, estimates that the average costs of a telehealth visit at USD 40-50, compared to USD 922 for an emergency room visit and that telemedicine could eliminate nearly 1 in 5 ER visits, which corresponds in numbers to almost two-thirds of those discovered to be non-urgent. Cardinal Health also states that 20% of ER visits require follow-up care for similar conditions, while only 6% of telehealth visits do. This echoes the spirit of the findings of the Wembley Community Hospital MATS study in 1996, mentioned previously.
Waiting times and demographic pressures
The problems with emergency medical care are similar in Britain. A&E waiting times have increased substantially over recent years, with many National Health Service (NHS) units failing to meet a four-hour standard for admission and discharge at national level. The number of people going to A&E has also risen substantially. In 2016/17 there were 23.4 million attendances at A&E departments – the equivalent of 63,000 attendances each day on average, and since 2011/12, this has been growing by 1.7 per cent each year – or the equivalent of an extra 5,100 each day.
These pressures have been exacerbated by closures. One in six A&E departments are being closed or downgraded, which corresponds to 33 casualty departments in hospitals in 23 areas of the UK.
The scourge of unnecessary visits
Unnecessary visits to A&E account for 16% of the total in England, but go over 50% in areas such as Durham and Darlington. From time to time, the media has a field day, citing lists from health officials about people going to A&E with broken false nails, splinters in their fingers, emergency contraception, as well as shaving and paper cuts.
The situation is similar in the US, where over 30% of visitors discover their case is not urgent – after being attended to. Some studies have estimated that 14 to 27 percent of ER visits could be treated at facilities like retail clinics or urgent care centres, with potential savings of USD 4.4 billion.
Telehealth to ‘redesign’ emergency medicine ?
A 2017 study from the University of Warwick calls for using telehealth to “redesign” emergency medical services. It chooses best of breed cases from different continents to make three cases:
• Specialists in underserved communities
• Pre-ambulance triage
• Ambulance-based triage
Providing patient access to remote specialists in underserved communities
In its early stages, emergency telemedicine applications were motivated by the need to provide more timely diagnosis and care to patients in underserved communities, in other words those lacking hospitals with full-time emergency medicine teams.
The Warwick study cites the Western Australia Emergency Telehealth Service (ETS, which comprises over 70 regional and remote hospital EDs as a “prominent example of this type of telehealth initiative.” The WA ETS makes specialist emergency medicine physicians available via videoconferencing to support regional hospital-based clinicians with the diagnosis and treatment of acute emergency patients. Another example in the Warwick study is the Cumbria and Lancashire Telestroke Network in Britain. This remote teleconsultation service connects 15 stroke consultants to provide ‘out-of-hours’ advice from their homes to hospital sites.
More recently, conclusive evidence about some of the above advantages has been obtained from another study at the University of Iowa’s Carver School of Medicine. The study found that telemedicine-equipped rural emergency departments provided patients with access to a clinician six minutes sooner than those in hospitals without the technology, regardless of whether or not telemedicine was used to intermediate the interactions. However, when telemedicine was used, as happened in 42% of the interactions, the door-to-provider time was shortened by nearly 15 minutes. This, according to lead author Nicholas Mohr, MD, an emergency physician and associate professor at the University, could change outcomes for patients with conditions like “severe trauma, stroke, myocardial infarction.”
Pre-ambulance triage, via teleconsultation with probable primary care patients
The second application highlighted by the Warwick researchers consists of pre-ambulance triage, via a system called ETHAN (Emergency Telehealth and Navigation). This was developed by the Houston (Texas) Fire Department in 2014, and combines teleconsultation, social services and alternative transportation. Its aim is to reduce the numbers of primary-care related patients being transported directly to the ED via fire-engine (although it could apply equally to ambulance). Apart from reducing ED patient loading, ETHAN makes substantial cost savings by eliminating unnecessary fire engine/ambulance journeys – estimated at USD 2500 per trip.
ETHAN equips EMS units with a Tablet to respond to patient initiated calls. Patients are connected via secure videoconferencing software to a hospital-based emergency physician who makes a diagnosis based on vital signs measured on scene by the field crew. After outlining treatment options, the physician then makes a final decision on whether the patient should be brought to the ED by fire engine/ambulance or via taxi, or taken by the latter to a primary care facility, or instructed on home care.
There is, however, little homogeneity in pre-ambulance triage, either in the US or elsewhere. In 2013, a systematic review of 120 publications by The Norwegian Knowledge Centre for the Health Services found that there was “a lack of scientific evidence about the effects of validated pre-hospital triage systems,” and called for further research.
Ambulance-based Triage
It has long been recognized that in-ambulance triage and care for an acute emergency patient during transportation to the ED, impact positively on patient outcomes, especially with time-critical conditions such as myocardial infarction and stroke. In several respects, Europe can be considered to be ahead of the US in this application. In Tucson (Arizona), a citywide ambulance telemedicine network, was shut down in 2011 due to budgetary problems and problems of reliability with the WiFi network.
On its part, the Warwick study reports on an ambulance-based telemedicine triage system with real-time bidirectional audio-video communication, carried out in Brussels. In 90 per cent of cases, preliminary pre-hospital diagnosis was formulated and was in agreement with in-hospital diagnoses. Failures, as had been the case in Arizona, resulted mainly from limited mobile connectivity.
Advanced ultrasonic protein removal technology: set to change how surgical instruments are cleaned
Standard methods of decontamination, such as Disinfector Washers (e.g. using hot alkaline solutions and surfactants), are known to be inconsistently effective in removing protein from surgical instruments. Advanced Ultrasonics offers an exciting and tantalizing alternative. Preliminary results suggest that intense cleaning using “advanced ultrasonic technology” can potentially result in disinfection without the need for any thermal or chemical methods.
by David Jones
In the UK, concerns about Creutzfeldt-Jacob Disease (CJD) date back to the mid-1980s when an outbreak of Bovine Spongiform Encephalopathy (BSE, a similar transmissible neuro-degenerative brain disease) in cattle raised concerns that the disease might be transmissible to humans. Confirmation came in 1996 [1] that BSE can indeed lead to a form of human CJD (variant (v)CJD) that particularly affected younger adults. This resulted in widespread public health concern, heightened again a few years ago when a study in the British Medical Journal [2] suggested that as many as 1 in 2000 Britons may be infected with the abnormal prion protein that causes vCJD. To date there have been 178 deaths due to vCJD in the UK with a few more elsewhere [3]. In both model experiments and in actual human studies it has been shown that the prion protein is readily transmitted on stainless steel instruments from one animal to another.
vCJD highlighted to clinicians and decontamination / sterile services professionals alike, the critical requirement to remove protein, as well as other infectious agents, from neuro-surgical and other reusable surgical instruments. In addition to the risk of patient-to-patient transferal of vCJD prions, there is a danger that bacteria hidden in or under any residual protein e.g. biofilms could also be passed on. A recent study in the journal Acta Neuropathologica [4] also highlighted the potential dangers associated with cross-contamination of neurosurgical instruments with the peptide amyloid beta (Aβ), a substance implicated in brain hemorrhages and Alzheimer’s disease.
Standard methods such as Disinfector Washers (e.g. hot alkaline solutions and surfactants) are known to be inconsistently effective in removing protein from surgical instruments [5,6] and other difficulties in ensuring consistent cleanliness has led to a move towards single use instruments. However, questions remain as to how manufacturers of single use instruments can achieve consistent cleanliness and sterility when modern, well equipped Sterile Service and Decontamination (SSD) units apparently cannot. Unfortunately, single use instruments are not always clean and sterile as recent unpublished investigations have shown.
In the UK, concerns about contamination mean that GPs and dentists, who have historically performed minor interventions such as lancing of boils, removal of small cysts and abscesses etc., are now being discouraged from doing so. This, in turn, is funnelling more patients to A&E departments, which are already under tremendous strain. Post-operative infections also add to strain on the health service, leading to extended hospital stays and bed-blocking.
There is a clear need for a new approach to improve the cleaning of surgical devices. “Commercial grade” ultrasonic cleaning systems have been available for a number of years and have been used as a first stage in the cleaning process.
Ultrasonics works via the process of cavitation. Transducers bonded to the base or side of a tank are excited by high frequency electricity causing them to expand and contract at very high speed. This mechanical action causes high speed downward flexure of the radiating tank face. The speed of this movement is too fast for the water in the tank to follow, resulting in the production of vacuum chambers. On the upward flexure the vacuums are released in the form of vacuum bubbles which rise up through the fluid until they hit an object, upon which the bubbles implode under high pressure, thus drawing away any contamination that may be on the surface of the object.
However, it has been shown that machines used in sterile services departments in the past have an erratic distribution of sound that does not consistently render instruments clear of residual protein. It was felt by many that a new way of applying ultrasound into a fluid was required. To achieve the safe cleaning of these items, the sound needs to be applied in a way that is both even as well as intense, with no gaps in activity where cleaning would not be effective.
In order to develop a new cleaning technology, a reliable method for measuring residual protein was needed and agreement reached on acceptable levels. The UK HTM 01-01 Guidance on the Management and Decontamination of Surgical Instruments [7], released in 2016, specifies that “there should be <5µg of protein in situ, on a side of any instrument tested”. In situ testing is specified since: “detection of proteins on the surface of an instrument gives a more appropriate indication of cleaning efficacy related to prion risk” than the swabbing techniques used in the past [8,9,10]. Currently the ProReveal system, from Synoptics Health, Cambridge UK, is the only in situ system on the market worldwide. As well as high levels of accuracy, the system also identifies the precise location of any remaining proteins on the instrument. To comply with UK HTM 01-01 guidance, therefore, any new cleaning system, ultrasonic or otherwise, needs to be validated against the levels of detection offered by ProReveal.
A second issue to be addressed by any ultrasonic cleaning technology is how to measure the ultrasonic activity. HTM 01-01 states that machines should be periodically tested for ultrasonic activity.
Historically, the only method available to Sterile Services Managers and AED’s for validating the activity in an ultrasonic tank has been to insert a piece of aluminium foil into the fluid for a set time and then visually analyse the indentations in the foil to determine the ultrasonic activity. This is a somewhat inaccurate way of validating what is a critical phase in the decontamination process. Troughs of sound can be either macroscopic or microscopic and, as such, the reliance on sight alone is unacceptable when such high levels of consistent cleanliness are expected.
With both these issues in mind, Alphasonics (a Liverpool/UK company with over 25 years’ experience in the field of ultrasonic cleaning systems) launched the ‘Medstar’ project with a view to developing ‘advanced ultrasonic technology’ for cleaning surgical equipment. The project started in 2013 but it was not until 2015 when a ProReveal was purchased that substantive advances were made. Progress then accelerated quickly and over a 3-year period, a point was reached whereby instruments could be rendered “completely” free of residual protein, as assessed by ProReveal technology.
To overcome the problems around accurately measuring ultrasonic activity, the world’s first Cavitation Validation Device (CVD) was developed from 2016 to 2018 which, for the first time, allows the validation of ultrasonic cleaning devices by listening exclusively for cavitation noise.
CVDs are included within most Medstar systems and the below graphs show how Medstar devices perform compared to existing ‘commercial grade’ ultrasonic cleaners (Data on File).
It is this unique, intense ultrasound technology that is so effective in removing protein residue from medical devices, as measured by the in situ ProReveal method. To assess the effect on removal of bacteria, a UKAS (UK Accreditation Service) accredited laboratory was engaged to carry out independent trials. Instruments were contaminated by the laboratory, first with Enterococcus faecium and Staphlyococcus aureus (as specified within ISO15883 annex N- “test soils and methods for demonstrating cleaning efficacy”) and then with “dirty” conditions (specified in ISO13727). They were then cleaned in a Medstar device. Since all residual protein was being removed, the question arose: was the (now exposed) bacteria also being removed by the intense ultrasound?
Work is on-going, but preliminary results suggest that intense cleaning using ‘advanced ultrasonic technology’ can potentially result in disinfection without the need for any thermal or chemical methods.
Medstar devices have several other features to allow compliance with UK HTM01-01 guidance, such as the Generator Output Monitoring System- which constantly monitors the generator output and adjusts the input accordingly, thus ensuring that the system is always performing optimally. The CVD device is then used for periodic independent validation.
Advanced Ultrasonics offers an exciting and tantalizing alternative to thermal disinfection devices. The HTM01-01 UK guidelines are only the start of things to come and it is already widely recognized that the 5µg limit set out in the guideline is still too high. The many trials undertaken by the manufacturer have clearly shown that the Medstar range of equipment leaves no more than 0.5µg of residual protein per side on an instrument and as such renders the bacteria fully exposed to the intense, very even, action of the ultrasound and enzymatic chemicals.
High throughput systems are also available that would be of great benefit to single-use instrument manufacturers and SSD units alike. These systems will deliver a consistently lower residual protein count and a better log reduction than thermal disinfection devices.
References
1. John Collinge, Katie CL Sidle, Julie Meads, James Ironside, Andrew F Hill. Molecular analysis of prion strain variation and the aetiology of “new variant” CJD. Nature, 1996; 383(6602), 685. doi:10.1038/383685a0
2. Gill O, Spencer Y, Richard-Loendt A, Kelly C, Dabaghian R, Boyes L, Linehan J, et al. Prevalent abnormal prion protein in human appendixes after bovine spongiform encephalopathy epizootic: large scale survey. British Medical Journal, 2013; 347, 11.
3. See www.cjd.ed.ac.uk/sites/default/files/figs.pdf
4. Jaunmuktane Z, Quaegebeur A, Taipa R, Viana-Baptista M, Barbosa R, Koriath C, Sciot R, et al. Evidence of amyloid-β cerebral amyloid angiopathy transmission through neurosurgery. Acta Neuropathologica, 2018; 135(5), 671–679. doi:10.1007/s00401-018-1822-2
5. Murdoch H, Taylor D, Dickinson J, Walker JT, Perrett D, Raven NDH, Sutton JM.
Surface de-contamination of surgical instruments – an ongoing dilemma. Journal of Hospital Infection 2016; 63: 432-438
6. Baxter RL, Baxter HC, Campbell GA, Grant K, Jones A, Richardson P, Whittaker G. Quantitative analysis of residual protein contamination on reprocessed surgical instruments. J Hosp Infect 2006; 63, 439-444.
7. Department of Health and Social Care. Health Technical Memorandum (HTM) 2006; 01-01: management and decontamination of surgical instruments (medical devices) used in acute care.. Available: https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care. Last accessed July 2018.
8. Nayuni N, Cloutman-Green E, Hollis M, Hartley J, Martin S, Perrett D. A critical evaluation of ninhydrin as a protein detection method for monitoring surgical instrument decontamination in hospitals. J Hospital Infection 2013; 84 97-102
9. Nayuni N, Perrett D. A comparative study of methods for detecting residual protein on surgical instruments. Medical Device Decontamination (incorporating the IDSc Journal) 2013; 18 16-20
10. Perrett D, Nayuni N. Efficacy of current and novel cleaning technologies (ProReveal) for assessing protein contamination on surgical instruments 2014; Chapter 22 in Decontamination in Hospitals and Healthcare Edited by Dr. J.T. Walker, Woodhead Publishers, Cambridge, UK.
The author
David Jones
Alphasonics, Liverpool, UK
www.alphasonics.co.uk
Fujifilm Medical Systems Europe highlights artificial intelligence initiative at ECR 2019 and celebrates 20 years of its Synapse PACS
This year at the European Congress of Radiology (ECR), Fujifilm displays its evolving portfolio of medical informatics and Enterprise Imaging innovations, presenting REiLI, its Artificial Intelligence (AI) technology initiative, and enhanced Synapse functions with SYNAPSE 3D CONSOLE MODE.
Fujifilm Medical Systems Europe will celebrate SYNAPSE’S 20-year anniversary and will present, REiLI the company’s global Medical Imaging and Informatics Artificial Intelligence (AI) technology initiative at the European Congress of Radiology (ECR) annual meeting to be held from February 27th to March 3rd, 2019 at the Austria Congress Center in Vienna, Austria.
Under the REiLI brand, Fujifilm is developing AI technologies that strongly support diagnostic imaging workflow, leveraging the combination of deep learning in its AI technology with the Company’s image processing heritage. Fujifilm’s artificial intelligence software is a work in progress and is not commercially available in Europe.
Applications currently in development include, but are not limited to: Region Recognition, an AI technology to accurately recognize and consistently extract organ regions, regardless of deviations in shape, presence or absence of disease, and imaging conditions; Computer Aided Detection, an AI technology to reduce the time of image interpretation and support radiologists’ clinical decision making; Workflow Support, using AI technology to realize optimal study prioritization, alert communications of AI findings, and report population automation. At Fujifilm’s in-booth AI Center, it will be possible to see live demonstrations of AI delivering enhanced workflows.
SYNAPSE 3D CONSOLE MODE is the powerful native Advanced Visualization workflow in Synapse PACS. Synapse 3D is designed to enhance visualization features in Synapse 5. It offers advanced 3D rendering in the Synapse PACS Viewer to perform fast and accurate extractions, stenosis measurements, brain perfusion CT, MRI, and more.
The Fujifilm Healthcare IT platform showcased at ECR includes also the comprehensive medical informatics and enterprise-imaging portfolio:
SYNAPSE 5 is our next generation PACS, Synapse is one of the fastest medical imaging solutions in the industry, offering sub second delivery of extremely large datasets. Its underlying architecture promotes significantly less bandwidth consumption and tighter security.
SYNAPSE VNA is the most secure, comprehensive application for ingesting, storing and providing access to the complete imaging record. It securely integrates more specialties, more devices, and more data than any other VNA.
SYNAPSE MOBILITY Enterprise Viewer uses the latest server-side rendering technology to stream imaging securely and quickly to any authorized user. It can be used within applications, directly from the EHR, or on our mobile device apps. Both within and outside of the Enterprise, giving access to imaging immediately and helping clinicians making the most informed and accurate decisions.
SYNAPSE 3D is an enterprise-wide solution for quickly accessing multiple Advanced Visualization processing tools (in excess of 50 modules). Designed for use across multiple specialties including radiology, cardiology, surgery and more. Full integration with Synapse PACS means one-click extremely fast image processing from any Synapse client.
SYNAPSE CWM, Clinical Workflow Manager, is the most advanced Radiology Information System on the market today. It continues to evolve to support the unique imaging and information needs in today’s radiology department. One platform can support acute care facilities, imaging centres, and radiology practices providing distributed diagnosis.
SYNCRO-DOSE is the Radiation Dose Index Monitoring system, compliant with the Directive 2013/59 / EURATOM of the European Union. Syncro-Dose is a comprehensive system for monitoring and managing patient radiation exposure at enterprise level across different imaging modalities and hospital facilities.
THE 20-YEAR ANNIVERSARY OF SYNAPSE: THE WORLD’S FIRST WEB- BASED PACS
In 1983, Fujifilm launched Fuji Computed Radiography (FCR), becoming the first company in the world to offer a digital X-ray diagnostic imaging system. Medical professionals quickly learned the merits of digital diagnostic images, including ease of storage and processing. They found that images from a variety of tests and procedures could be shared within and among facilities, and the images could even be used for remote diagnosis and consultation. Recognizing this trend, Fujifilm saw the opportunity to leverage the technologies it had developed for FCR and contribute to the evolution of connectivity within and among medical facilities. What made Fujifilm’s SYNAPSE concept different was that it used the emerging Internet and web technologies instead of private networks. It was, in essence, a Web-based PACS: the first in the world.
Offering outstanding medical connectivity based on the convenient and efficient sharing of information, SYNAPSE made possible initial diagnosis at a local clinic, followed by more complete testing and treatment at a larger medical facility, in turn followed by periodic monitoring at the original local clinic. SYNAPSE’s rapid rate of adoption was due in large part to its capability, to contribute significantly to the quality of medical care, including support for the important objective of informed consent. Nowadays 5000 Synapse PACS systems are installed in healthcare facilities around the world, earning the largest market share worldwide (estimation based on a set of data from multiple market research studies), and last September “SYNAPSE 3D” (also known as Synapse Vincent in some global markets) a 3D image analysis system, won the Red Dot Award: Communication Design 2018 – the prestigious international design award in recognition of superior design, outstanding performance, and excellent operability.