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At least 757 records · Page 42Linked to original sources
PubMed2005

[Problems of emergency transfers of patients after a stroke. Results of a telemedicine pilot project for integrated stroke accommodation in southeast Bavaria (TEMPiS)].

BACKGROUND: Specific stroke subtypes like subarachnoid hemorrhages or malignant brain infarcts require immediate interventions, but treatment options are offered mainly in specialized centers. For this reason, interhospital transfers from primary hospitals need to be done without delay. METHODS: The telemedic pilot project for integrative stroke care (TEMPiS) connects 2 stroke centers and 12 regional hospitals in Bavaria (Germany). Core elements are the implementation of stroke wards, telemedic consultation and improvement of emergency interhospital transfers. Organization of patient transports is offered by the central telemedic service. During the first 12 months of the continuing project all interhospital transfers initiated by the central telemedic service were prospectively documented. Emergency transports were analysed according to diagnosis, type of transport, distance and time delays. RESULTS: A total of 252 interhospital transfers were recommended in teleconsultations; finally 221 transports took place. Median total duration of transfers (including the necessary arrangements) was 134 min (interquartile range: 105-219) for intracerebral hemorrhages (N = 58), 138 min (95-157) for subarachnoid hemorrhages (N = 31), 161 min (100-230) for malignant infarcts (N = 22) and 147 min (109-180) for suspected basilar artery occlusion (N = 28). Time from admission in the primary hospital to initiation of interhospital transfer was 135 min (median; interquartile range: 86-172), transport time was 81 min (60-116). Helicopter transport did not save time for transfer distances up to 50 kilometres, compared to transport via ambulance (including assistance of hospital physicians). Transport using a special intensive care vehicle was much more time consuming because of the longer transport preparation time. CONCLUSION: Emergency transfers of stroke patients are time consuming. This may contribute to additional harm being done to severely ill patients. Faster organization and conduct of transports is required.

Brain Infarction↗
PubMed2004

Telemedicine for safe and extended use of thrombolysis in stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria.

BACKGROUND AND PURPOSE: Systemic thrombolysis represents the only proven therapy for acute ischemic stroke, but safe treatment is reported only in established stroke units. One major goal of the ongoing Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria is to extend the use of tissue plasminogen activator (tPA) treatment in nonurban areas through telemedic support. METHODS: The stroke centers in Munich-Harlaching and in Regensburg established a telestroke network to provide consultations for 12 local hospitals in eastern Bavaria. The telemedic system consists of a digital network that includes a 2-way video conference system and CT/MRI image transfer with a high-speed data transmission up to 2 Mb/s. Each network hospital established specialized stroke wards in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 hours per day. RESULTS: A total of 106 systemic thrombolyses were indicated via teleconsultations between February 1, 2003, and April 7, 2004. During the first 12 months, the rate of thrombolyses was 2.1% of all stroke patients. Mean age was 68 years, and median National Institutes of Health Stroke Scale score was 13. Mean delay between onset and hospital admission was 65 minutes, and door-to-needle time was on average 76 minutes, which included 15 minutes for the teleconsultation. Symptomatic hemorrhage occurred in 8.5% of patients, and in-hospital mortality was 10.4%. CONCLUSIONS: The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas.

Aged↗
PubMed1996

Emergency echocardiography telemedicine: an efficient method to provide 24-hour consultative echocardiography.

OBJECTIVES: This study sought to assess the clinical utility of interpreting emergency echocardiograms after regular working hours through a telemedicine connection to on-call cardiologists. BACKGROUND: Physician interpretation of emergency echocardiograms is often delayed during weekends, evenings or night hours. This delay places undue responsibility on less qualified personnel to interpret echocardiograms of vital importance. METHODS: Digital quad-screen cine-loop format was transmitted over standard telephone lines. Clinical data and conventional and telemedicine interpretations were collected prospectively for 187 emergent or semiemergent tele-echocardiograms after regular working hours. RESULTS: Indications for the echocardiogram included assessment of left ventricular function, ischemia, pericardial effusion, valvular disease, heart donor status and arrhythmia. Three off-site echocardiographers received the standard echocardiogram and spectral, gray-scale and color flow Doppler images in cineloop format using a laptop computer. Laptop interpretation showed 19 technically limited studied, 153 abnormal studies and 54% with wall motion abnormalities. Overall mean agreement rate between telemedicine laptop interpretation and conventional workstation interpretation performed in blinded manner for serious disorders with classic echocardiographic findings (pulmonary hypertension, left ventricular thrombus, aortic dissection, severe valvular insufficiency and large pericardial effusion) was 99.0% (95% confidence interval [CI] 96% to 99%). For serious wall motion abnormalities, the agreement rate was 96.3% (95% CI 92% to 99%). The following mean times elapsed after completion of the echocardiogram: to laptop fax report, 2.14 (range 10 min to 8 h); to dictation of videotape, 11.74 h (p < 0.001); to transcription of videotape diction, 56.6 h (p < 0.0001). CONCLUSIONS: After-hours emergency echocardiography telemedicine using a laptop computer is more rapid than scheduled conventional interpretation from a videotape workstation, yet diagnostic accuracy is comparable.

Adolescent↗
PubMed2000

The cost-effectiveness of teleneurology consultations for patients admitted to hospitals without neurologists on site. 1: A retrospective comparison of the case-mix and management at two rural hospitals.

We are currently evaluating the use of telemedicine for improving the care of patients admitted with neurological symptoms to hospitals that do not have specialist neurologists on site. To do this we have been comparing the outcome of patients admitted to two small hospitals. In one hospital all patients with neurological symptoms are seen by a neurologist at a distance using an interactive video-link transmitting at 384 kbit/s; in the other patients with neurological problems are managed as per usual practices. For the results of this study to be valid, it is essential that the case-mix and process of management for neurological patients are similar at the two hospitals. We therefore compared the case-mix, process of management, and outcome for all patients admitted over a four-month period to either hospital who had been coded using ICD-10 as having a final diagnosis of a neurological condition. No appreciable differences were noted between the two hospitals for measures of case-mix or outcome. Likewise, most measures of process were similar, although there was a significant difference for the overall length of hospital episode between the two hospitals. When patients with prolonged hospital episodes were excluded, or only patients with a diagnosis of headache, epilepsy or transient ischaemic attack were considered (who as a group made up the bulk of neurological admissions), the difference in the length of hospital episode was not significant. It should therefore be possible for us to estimate the effect of telemedicine on the management of patients with neurological problems.

Cohort Studies↗
PubMed2006

[Improvement in stroke care in a non-urban community hospital--quality of procedures before and after participating in a telemedical stroke network].

BACKGROUND: Although treatment in a stroke unit has been proven to be effective, most stroke patients in rural areas have no access to it. The community hospital of Ebersberg (Bavaria/Germany) joined the Telemedic Project for Integrative Stroke Care (TEMPiS) in order to optimize the quality of stroke care. This analysis focuses on changes in stroke management using generally accepted indicators for quality of acute stroke treatment. METHODS: The core elements consisted of the setting up of a stroke ward in the community hospital, continual stroke education and a 24-hour telemedical consultation service offered by stroke centers. Treatment of stroke patients was documented during two 12-months periods before the project was started start (i.e. retrospectively) and during the course of the project (prospectively). In addition, data on fatal outcome and institutionalization of patients who had lived at home before the qualifying event were collected 12 months after stroke onset. RESULTS: There were 299 admissions for stroke or transient ischemic attacks between 1 Nov 2001 and 31 Oct 2002, and 305 between 7 July 2003 and 6 June 2004. Length of in-hospital stay decreased from 12.1 to 9.2 days. More patients (10.3 vs. 1.3%) were transferred to other acute hospitals during the later period. Indicators for stroke care quality improved: numbers of cerebral imaging rose from 56.5% to 96.4%, of duplex sonography of cervical arteries from 43.5 to 72.8 %, of speech therapy from 0% to 50.8% and of occupational therapy from 0 to 33.4%. One year after admission, 18.9% and 17.2%, respectively, of the patients had died, while 10.2% and 6.1% were living in institutions. CONCLUSION: Participation in the TEMPiS network substantially improved stroke care quality according to national and international guidelines. These improvements may lead to a better prognosis after a stroke.

Computer Communication Networks↗
PubMed1998

Is image selection a useful strategy to decrease the transmission time in teleradiology? A study using 100 emergency cranial CTs.

This study examines the suitability of working with a selection of images in a teleradiology consulting system in neurological or neurosurgical emergency situations. The teleradiology system was based on IBM-compatible personal computers, video digitization for data acquisition, and data transmission by Integrated System Digital Network. Forty normal and 60 abnormal emergency cranial computed tomograms were shown to a radiologist on call who presented all cases he regarded as pathologic to a neuroradiologic expert by teleradiology. To reduce transmission time, only a selection of images from the CT study was presented (up to four images per case). For each case the on-call radiologist's diagnosis (D(on-call)), the expert's diagnosis on the teleradiology screen (D(monitor)), and the expert's diagnosis on the original film (D(original)) was documented, together with an estimation of the agreement between those diagnoses. There was clinically relevant disagreement between the on-call radiologist's diagnosis and the neuroradiologist's diagnosis based on the image selection on the teleradiology monitor in 23% of cases. A clinically important discrepancy between the neuroradiologist's diagnosis based on the image selection and his diagnosis using the original films was found in 30% of cases. This was due to the presence of clinically relevant information on images not transferred by the on-call radiologist. Image quality of the transferred images was sufficient in all cases. Drastic selection of images from a complete CT study leads to a high rate of incorrect diagnoses and is not appropriate to reduce transmission time in teleradiology.

Humans↗
PubMed1995

Creating a computer-aided intellectual environment for a consultative center of intensive care.

A consultative centre for intensive pediatrics (cip) is a center for rendering aid to children in urgent conditions who are hundreds kilometers from specialized help. Such aid is typically rendered by: 1)moving the patient to the another hospital, 2) the specialized team going out by plane, or 3) consulting the local physician by phone. The complexities of the cip dispatcher-consultation of the local physician entail a real-time system that provides a consultant with simultaneous operation with a computer and a local doctor over a phone. In 1987, a computer program, DINAR-1, was used. The core of this program was the scale of a patient's state severity "FHD-5.4" and essential elements of informative services: both a reference subsystem and one accumulating and analyzing data about cip activities, treated patients, and faults in the system of medical care. Two years of DINAR-usage showed the necessity of strengthening the decision support system for cip consultant. In 1989, a new program variant, DINAR-2, was completed. During the new variant's creation, we developed a model of decision making under conditions of information distortion (e.G., as a result of the subconscious influence of diagnostical hypotheses). This model was necessary for DINAR-2, because the most part of all information for decision making had subjective issue. Distinctions between levels of medical aid at the spot (in local hospitals) demanded the special assessment of a patient's state severity in order to adequately choose between tactical activities of the CIP. The severity of a patient's state original index depended on necessary therapy type; volume was developed. Special methodological interaction expedients between the user and the decision making system were verified in DINAR-2. The following improvements were also developed: subsystem of tuning on a definite area (1990); block of analytical final instructions on a patient's treatment (1991); visualization of introduced information (1991); determination of factors causing aggravation of a patient state (1992); and specialized subsystem of consultation of neonatals (1993). During the work, CIP got a new important function. CIP became a methodical center of the medical children aid. In keeping with this, a collection and analysis of information for regional health ministry became important part of DINAR-2. It is especially connected with touched discovery and analysis of medical defects. A system of child's death-rate analysis was especially created to make impartial decisions (1990). Expert subsystems had also an original continuation. This subsystem became a basis of the new system DINAR-created for the common pediatric physician who is attending a severely ill child. A principle addition to this system is a more complicated method of tactic solution choice. The technology of CIP supported by DINAR-systems had been bought by 35 different regions of the former USSR by 1994 (1989: one region; 1990: 2; 1991: 5; 1992: 10; 1993: 17 regions). The total population of all these regions is more than 59,000,000 people, and the total area is more than 11 million square kilometers. The main direction of DINAR's development is the creation of a regional computer network, allowing DINAR-to communicate with DINAR-in local hospitals. The first place for the usage of such a network is going to be the Big Urals Region. Big Ural consists of eight states. The total population of this territory is 28 million people and total area is 3.1 million square km. Computer networks will link eight regional CIPs to one another and the medical analytical center. The CIPs will have to be connected with 259 local hospitals. At present, the DINAR-2-CIP is installed in six states of the Big Ural, and DINAR-H is installed in four hospitals of the Sverdlovsk state.

Child↗
PubMed2000

Assessment of the accuracy of low-cost store-and-forward teledermatology consultation.

BACKGROUND: Telemedicine has the potential to revolutionize the delivery of dermatologic care to underserved areas. OBJECTIVE: Our purpose was to compare diagnoses from two types of dermatology consultations: telemedicine using store-and-forward (SAF) technology, and traditional face-to-face (FTF) office visits. METHODS: Skin conditions were imaged with a consumer-grade digital camera. A standardized template was used to collect historical data. Information was stored in a secured database for access by 2 or 3 board-certified dermatologists. Results from the FTF visit were used to assess the accuracy of the SAF diagnoses. RESULTS: A total of 106 dermatologic conditions in 92 patients were included. Concordance between FTF and SAF diagnoses was high, ranging from 81% to 89% for all 3 dermatologists. Clinically relevant disagreement occurred in only 4% to 8% of cases. Remaining disagreements did not affect patient care. Diagnostic confidence and image quality affected agreement. When cases of high confidence were analyzed separately, agreement increased to 88% to 100%. This increase was substantiated by means of a chi-square test between the high confidence and low confidence groups, which demonstrated statistical significance (P <. 005) for all dermatologists. Similarly, when cases of above average image quality were considered, agreement increased to 84% to 98%. Again this difference was substantiated by means of a chi-square test between adequate and poor images, with statistical significance for two dermatologists (P <.001). Accuracy was comparable between disease types with the exception of benign neoplasms, which demonstrated agreement of 22% to 46%. CONCLUSION: These data support the use of existing digital technology to construct an accurate SAF teledermatology system. The inexpensive camera and widely available computer equipment make this an extremely affordable system. Furthermore, participating dermatologists appear well aware of system limitations, as reflected in the increased agreement for high confidence cases. Additional investigation of the accuracy of teledermatology for benign neoplasms is warranted.

Adolescent↗
PubMed2004

Safety of telephone consultation for "non-serious" emergency ambulance service patients.

OBJECTIVE: To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls). DESIGN: Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted. SETTING: Ambulance services in London and the West Midlands, UK. STUDY POPULATION: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified. MAIN OUTCOME MEASURES: Assessment of safety of triage decisions. RESULTS: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system. CONCLUSIONS: Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Ambulances↗
PubMedDate not supplied

The department without walls. Acceptability, cost, and utilization of interactive video technology.

As groups of physicians continue to provide more of their activities in sites remote from the central office, communication among providers and staff and the provision of common educational activities are important priorities. An analysis of a 12-month period of the use of full-motion interactive video technology to accomplish these goals in a decentralized academic department shows this method to be acceptable and cost-effective. Careful attention to room environment and staff support were found to be important. Practical recommendations are provided for those considering the use of this technology.

Academic Medical Centers↗
PubMed2000

Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care.

BACKGROUND: Primary care treatment of depression needs improvement. OBJECTIVE: To evaluate the efficacy of 2 augmentations to antidepressant drug treatment. DESIGN: Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months. SETTING: Two managed care adult primary care clinics. PARTICIPANTS: A total of 302 patients starting antidepressant drug therapy. INTERVENTIONS: For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression. MAIN OUTCOME MEASURES: For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction. RESULTS: Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes. CONCLUSION: Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.

Adult↗
PubMed2006

Accuracy and reliability of remote retinopathy of prematurity diagnosis.

OBJECTIVE: To determine the accuracy and reliability of retinopathy of prematurity (ROP) diagnosis using remote review of digital images by 3 masked ophthalmologist readers. METHODS: An atlas was compiled of 410 retinal photographs from 163 eyes of 64 low-birth-weight infants taken using a wide-angle digital fundus camera. All the images were independently reviewed by 3 readers, and the diagnosis in each eye was classified into 1 of 4 ordinal categories: no ROP, mild ROP, type 2 prethreshold ROP, or ROP requiring treatment. Findings were compared with a reference standard of dilated indirect ophthalmoscopy with scleral depression performed by an experienced pediatric ophthalmologist. RESULTS: Sensitivities/specificities of the diagnosis of any ROP were 0.845/0.910 for the first reader, 0.816/0.955 for the second reader, and 0.864/0.493 for the third reader. Sensitivities/specificities of the diagnosis of ROP requiring treatment were 0.850/0.960 for the first reader, 0.850/0.973 for the second reader, and 0.900/0.953 for the third reader. When ROP was classified into ordinal categories, the overall weighted kappa for interreader reliability was 0.743. Intrareader reliability for detection of low-risk prethreshold ROP or worse was 100% for all readers. CONCLUSION: The accuracy, interreader reliability, and intrareader reliability of remote diagnosis of clinically relevant ROP based on digital imaging are substantial.

Birth Weight↗