Abstract
The adoption of telemedicine and all its applications (from telediagnosis
and second opinion teleconsultation to feasible teleassisted therapeutic
interventions) can be translated into greater operational efficiency,
resource optimisation and spreading of know-how. These technologies
are considered potentially useful for the management of patients
suffering from stroke (Telestroke) and of those who have suffered
head injury. A project based on the application of an innovative
protocol for the sharing of diagnostic images and clinical data
between hospitals in the provincial territory (Messina Local Health
Administration n° 5 ) and the neurosurgical centre has been
implemented in Messina for the management of head injuries. The
project will implement guidelines through the use of a modern
computerised tool.
The study is based on the data analysis of a population of 684,703
inhabitants resident n the province of Messina. The population
was divided in three groups: the first group (Group 1) comprising
262,224 residents in the urban area; the second group (Group 2)
comprising 211,139 people resident in extra-urban areas, which
refer to hospitals where a teleconsultation system has been installed.
Lastly a third group (Group 3) comprising 211,340 people resident
in extra-urban areas, which refer to hospitals where a teleconsulting
system is not available. Study results were assessed by analysing
the achievement of three distinct goals: health care efficacy
goals, training goals and economic and health goals. The data
obtained has proved the usefulness of these technologies based
on Information Communication Technology (ICT) in the management
of head injuries and other neurosurgical emergencies such as stroke.
Patients assisted through the implemented telemedicine system
reached adequate diagnostic and treatment standards, which were
comparable with those of patients directly treated in the specialist
centre, avoiding the risk of unnecessary transport and optimising
resources. Neurosurgical expertise was shared with non-specialist
personnel with an increase in treatment that closely followed
guidelines. The technological tool adopted has proved effective
in patient management.
Introduction
Stroke is the third cause of death in Europe and it is the most
important cause of morbidity and permanent disablement. Head injuries
are the most frequent cause of death in young adults. These emergency
conditions, which concern neurosurgeons, must hence be recognised
as national emergencies in medicine. The therapeutic success of
patients suffering both from a severe cerebrovascular event and
from head injury depends on certain essential conditions:
1) quick recognition of clinical conditions;
2) immediate involvement of medical emergency systems;
3) preferential transport to a hospital; and,
4) speedy accurate diagnosis and treatment in a specialist environment.
Despite the social impact of neurosurgical emergencies, direct
immediate access to neurosurgical expertise is often limited since
in Italy, as throughout the world, a single centre serves an extensive
geographical area. Such a condition places the problem of neurosurgical
emergency management in non-specialist environments. Data published
in literature on the management of such emergencies tends to report
information collected in large centres, while the data collected
in suburban centres or in extra-urban areas, where however a high
mortality rate has been proved for low risk patients, is virtually
never reported1. A relevant point, in this regard, is that both
in Europe and in the USA most patients with head injuries are
managed in the suburbs2, 3 and that half the fatal events subsequent
to head injuries occur in hospitals in the suburbs. This information
becomes relevant in major head injuries, but it is also important
for minor head injuries, which, given their frequency, have greater
social impact and can be considered a quality indicator of the
health system. Guidelines for the treatment of serious and moderate
head injuries outlined by the Italian Society of Neurosurgery’s
(SINch) head injury study group coordinated by the University
of Messina’s Neurosurgery Clinic4 were introduced in our
plan to obtain treatment standards, which do not depend on the
site where the patient is managed. However recent studies have
proved that both in the USA5 and in Europe6 the application of
treatment standards is still far from being achieved. One of the
reasons for this difficulty in spreading the application of guidelines
is the lack of interaction between suburban centres and the specialist
centre, especially at an initial stage of patient management.
The increasing widespread use of telemedicine (telediagnosis and
teleconsultation)7 has opened sectors, which were not the focus
of national guidelines’ special consideration. In particular,
the adoption of telemedicine and all its applications (from telediagnosis
and teleconsultation of a second opinion to feasible teleassisted
therapeutic interventions) can be translated into greater operational
efficiency, resource optimization and spreading of know-how. In
this perspective a telematic data transmission system based on
Information Communication Technology (ICT) enables quick and appropriate
diagnostic stratification of patients with a neurosurgery-related
disease sent from suburban hospitals, with the subsequent selection
of patients sensitive to emergency treatment, thus creating a
privileged special health care track for most of them.
A project for the management of head injuries and all other neurosurgical
emergencies has been implemented in Messina. The project is based
on the application of an innovative protocol for sharing diagnostic
images and clinical data between suburban hospitals and the neurosurgical
centre to implement the SINch’s guidelines through the use
of a modern computerised tool.
Material and methods
The study was co-financed by the Ministry of Education, Universities
and Research (MIUR) through the approval of a research project
for the implementation – based on developing information
technologies - of guidelines for the treatment of serious head
injuries. The project does not only focus on a mere assessment
of the clinical impact, but also on the social, training and economic
impact of telemedicine in the management of head injuries, stroke
and other neurosurgical emergencies.
The study was coordinated by the University of Messina’s
Neurosurgical Clinic partnered by the Messina Local Health Administration
No. 5’s hospitals in Barcellona P.G. (Lipari), S. Agata
Militello and Taormina, besides the firm TelBios S.p.A., which
was formed as a joint-venture between Alenia Spazio S.p.A. and
Parco Scientifico Biomedico San Raffaele S.p.A.
Demographic data
The study is based on data analysis of the population resident
in the province of Messina comprising 684.703 inhabitants. The
province’s extra-urban territory comprises many rural and
mountain areas and 7 islands. The population was divided in three
groups figure 1. The first group (Group 1) numbering
262,224 people comprised the population resident in the urban
area. The second group (Group 2) comprised 211,139 people resident
in extra-urban areas, which refer to suburban hospitals where
a teleconsultation system has been installed. Lastly a third group
(Group 3) comprising 211,340 people resident in extra-urban areas,
which refer to suburban hospitals where a teleconsultation system
cannot be found.
All patients visiting hospitals in the province in the period
between 15 July 2003 and 15 July 2004 were included in this study.
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Teleconsultation system
The teleconsultation system was applied through prior telephone
contact directly from the suburban hospital’s Emergency
Department. This contact was followed by a consultation based
on X-rays and relevant clinical data. After studying the images
the neurosurgeon offered a second opinion assessment.
Linked hospitals were provided with a PACS (Picture Archiving
and Communication System) archiving and image transmission system.
The possibility of using a workstation furnished with the software
iPACS and technology Pixel-on-demand to study images taken in
the suburbs enables real time image streaming to every client
location directly from the archives with no loss of quality. Pixel-on-demand
is a streaming technology, which transfers in real time only pixels
requested from the region concerned (ROI), which is studied at
a certain moment. This technology requires neither off-line processing
nor image storage in consultation workstations, nor does it require
a change in image format.
Image resolution is defined by the system used by those consulting
the image taken in the suburbs (i.e. monitor). When the ROI reaches
the teleconsulting system, the ROI and not the entire image is
gradually decoded. Hence when the image is zoomed or the physician
moves on to the next image the server encodes the missing part
of the image in real time and sends it to the consultation system.
Hence the iPACS system used enables to consult images recorded
in the suburbs in DICOM format (Digital Imaging and Communications
in Medicine) through a high speed LAN network, which is associated
to a safety ISDN network. The fact that images are consulted rather
than transferred prevents a loss of quality and enables to provide
real time consultation without archive duplication, thus increasing
the system’s safety.
Assessing the outcome
Study results were assessed by analysing how far the three study
goals were reached: clinical-health care goals, training goals
and economic-health goals.
Results obtained in the clinical and health care sector were analysed
by studying the number of second opinion evaluations in the three
groups, clinical outcome and how the consultation was conducted
(i.e. the time elapsed between the patient’s arrival in
the Emergency Department and specialist neurosurgical assessment).
The project’s training efficacy was assessed by evaluating
the application of guidelines and how closely the operator followed
treatment protocols. This phase also evaluated the number of procedures
performed during the year to assess operators’ trust in
the project and its efficacy.
The teleconsulting system’s economic impact was analysed
by studying the number of appropriate and inappropriate admissions,
the number and method of transport of patients and the use of
economic resources in a broad sense.
Results
A total number of 333 specialist neurosurgical teleconsultations
was performed during the study period considered. Teleconsultations
requested for head injuries were 55% (n° 185): stroke 35%
(n° 116), brain tumours 5% (n° 17) and spinal injuries
5% (n° 15). Such data is summarised in figure 2.
Only 33% of patients were brought to our attention following teleconsultation,
while 67% was kept under observation in frontline suburban hospitals
figure 2.
User population stratification in three groups separated by area
(Group 1: urban area; Group 2: area furnished with telemedicine;
Group 3: area not furnished with telemedicine) enabled to mainly
mark out the number of teleconsultations performed in the various
areas of origin. Specialist consultations in group 1 numbered
1,244, while those in groups 2 and 3 were respectively 333 and
168 figure 3.
The analysis of results collected also enabled to mark out the
various types of injuries when they caused neurosurgical disorders
requiring teleconsultations. In this perspective in 54% of cases
the disorders analysed resulted from road accidents, in 23% they
were caused by domestic accidents, in 8% by work accidents, in
7% by violence or aggression and in 6% by other causes figure
4.
The outcome of patients who have undergone a teleconsultation
was assessed by applying the Glasgow Outcome Scale (GOS). Most
patients (>80%) presented a GOS of 4-5 (Good recovery-moderate
disability), while only a small percentage presented a lower GOS.
No statistically significant differences were noticed between
the GOS presented in the various groups analysed figure
5.
The health care contribution offered by telemedicine also enabled
to cut down to the minimum the time elapsed between patients’
admission and the start of the appropriate surgical management
(on site or at a distance). In fact patients belonging to groups
1 and 2 received adequate diagnostic and therapeutic treatment
in a time period within the first 60 minutes after the injury,
while in patients belonging to group 3 this time exceeded 150
minutes figure 6.
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The analysis of preliminary data concerning this early stage
of observation enabled to evaluate the concrete contribution concerning
the spreading of guidelines on mild brain injuries (GCS 14-15)
and national guidelines for the diagnosis and treatment of stroke
(SPREAD 2003). Along with the total number of patients belonging
to group 1, over 87% of patients visiting centres linked by telemedicine
received management specified in the guidelines, while this percentage
dropped to about 20% in patients belonging to group 3 figure 7.
This management has significantly influenced the number of patients
transferred to the reference neurosurgical centre. Of all patients
transferred, 40% belonging to group 2 underwent surgical treatment,
while little less than 20% of patients belonging to group 3 underwent
surgical treatment.
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Discussion
The study assessed the impact of a telemedicine system in the
management of head injuries and in neurosurgical emergencies in
extra-urban areas by comparing results obtained in the local urban
population with those obtained in two extra-urban populations
with a similar demographic distribution - one of the latter was
furnished with a teleconsulting system.
In the framework of specialist competences, such as neurosurgery,
extra-urban populations can present a disadvantage due to the
lack of such competences in the territory. Offering populations
resident in rural areas the best guarantees of treatment is a
problem of considerable social and economic relevance. The definition
“rural” must be applied, as suggested by the American
College of Surgeons’ Committee on Head Injuries8, on the
basis of a special geographical layout and also to all those areas
where, for various reasons, the patient lacks immediate access
to the best treatment resources.
Telemedicine and teleconferences are innovative technologies designed
to overcome such difficulties. They can improve the head injury
system and extend the application of guidelines to the suburbs.
As already considered by Gray et al. telemedicine systems can
improve the management of patients who have suffered head injuries
in three different areas: confirm the diagnosis, direct treatment
procedures preceding a possible transfer and resource optimisation9.
The first study conducted on a modern telemedicine system appeared
in 199410; it was however a study based on a scarce number of
cases. A more recent study describes an Irish experience in which
many suburban centres were linked to the country’s two neurosurgical
units11. An experience achieved in Hong Kong documented how unnecessary
transfers were cut down to 21% and adverse events occurring during
the transfer were reduced from 32% to 8% with a mutually agreed
reduction in patient transfer times12. In 2002 Servadei et al.
published the results of a study, which collected data of over
1,500 patients13.
Unlike the abovementioned studies, this study did not only aim
at assessing the system’s impact on the patient’s
clinical outcome, but it also checked the training and economic
value of the procedure used. Hence it divided the user population
in three groups, which mirrored three different access conditions
to neurosurgical evaluation. The two populations resident in extra-urban
areas presented many similarities in demographic composition,
in the geographical features of the area of residence and in the
distribution of health resources, thus enabling reliable data
comparison.
Result analisys
A comparative study of the two populations resident in extra-urban
areas highlighted a significant difference in the percentage of
patients transferred following a “second opinion”
neurosurgical consultation. In fact this percentage was 33% in
Group 2, which counts on a teleconsulting system, whereas patients
from extra-urban areas that are not provided with the abovementioned
system (Group 3) are kept in the neurosurgical centre (p<0.001).
However it is best to consider that avoiding an ill-advised transfer
has both an economic and clinical advantage. In fact the transfer
of patients in critical general conditions can at times be associated
with secondary effects such as hypoxia and hypotension, which
increase morbidity and mortality as proved by Goh et al.12 Hence
the admission to a neurosurgical environment does not alone guarantee
the best therapeutic choice for the patient. Hence the need to
assess whether the choice of maintaining the patient in the suburbs
can ensure his clinical conditions’ safe management. Our
study documents how the presence of a teleconsulting system offers
the opportunity to obtain clinical result standards, which are
comparable with those obtained in the urban area.
Another clinical advantage resulting from the use of a teleconsulting
system is the spreading and sharing of neurosurgical know-how
and of experiences. Before a teleconsulting system was introduced
in our area about 160 images were yearly transferred between suburban
hospitals and the neurosurgical centre. It is interesting to note
that though the number has doubled since the system was introduced,
the number of admissions to the reference centre has remained
more or less the same. This means that a considerable number of
patients with head injuries were once managed in the suburbs without
a specialist assessment.
This last consideration leads us to the study’s second endpoint
– such a system’s training value. Experience and competence
sharing was assessed by analysing the application of guidelines.
Considering the fact that patients with moderate to severe head
injuries were centralised, the problem of the application of guidelines
essentially concerns patients with mild injuries. In this framework
the use of the teleconsulting system has enabled to closely follow
guidelines in 87% of cases against only 20% of cases in which
patients were warded in centres where the system was not available.
Resource optimisation and the absence of deterioration in the
suburbs also confirm that treatment standards were closely followed.
In fact only 1.5% of patients was transferred following a second
opinion and in no case could the mortality rate be referred to
delayed treatment. The procedure’s value is also documented
by operator’s satisfaction and by increasing trust in the
system witnessed by the number of consultations, which gradually
increased as months went by figure 8.
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The assessment of economic and health care goals achieved was
another endpoint of the study. The economic advantages of a similar
system are extensively recognised. Our study confirms it, documenting
the reduction in unnecessary transfers and the optimisation of
resources. In fact, in Group 2 where patient management was modulated
by the teleconsulting system the percentage of patients transferred
who underwent surgery was 40% against only 16% of patients in
the group that did not have the system.
Conclusions
The number of requested consultations and of patients transferred
to the reference neurosurgical centre for surgical treatment clearly
shows the project’s efficacy. Patients managed through the
telemedicine system adopted have reached adequate treatment standards,
which are comparable with those directly managed by the specialist
centre, avoiding transport-related risks and optimising resources.
Neurosurgical expertise was shared with non-specialist personnel,
thus increasing the number of treatments, which closely followed
guidelines. The technological tool adopted has hence proved effective
in the management of patients affected by stroke, other cerebrovascular
emergencies and post-trauma disorders.
Prof. Francesco Tomasello
Clinica Neurochirurgica
Universitá degli Studi di Messina
