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MUSC Annual Report 2011-2012

Using Telemedicine to Help Distant Trauma, Sepsis Patients

Somewhere in the middle of the night, a patient is brought to a rural hospital complaining of fever and flu-like symptoms. Almost immediately, however, the patient's condition deteriorates and he goes into shock. The staff are not equipped to properly diagnose and manage the patient's treatment, they work to stabilize the patient and phone a larger medical center in an attempt to transport him. Crucial minutes elapse as this logistical dance is arranged, and the patient's outcome may depend on the accuracy of the diagnosis and the timeliness of the transport.

Such a scenario occurs frequently throughout South Carolina and the country.  Thanks to a federally-funded program involving the Medical University of South Carolina and select hospitals in the Lowcountry and Pee Dee regions, similar occurrences may fade into the past.

Under the acronym CREST (Critical Care Excellence in Sepsis and Trauma), Dee W. Ford, M.D., and Samir M. Fakhry, M.D., established a telemedicine network with several smaller hospitals in eastern South Carolina. The project was modeled after the successful REACH (Remote Evaluation of Acute IsCHemic Stroke) program operated by Robert J. Adams, M.D.

Underwritten three years ago by a federal grant, the program is now in the evaluation phase, but something similar is expected to be proposed in the future, they say.

Using telemedicine technology, MUSC staff and staffs from participating hospitals have an audiovisual connection, enabling them to see and hear each other, as well as seeing the patient, resulting in a more thorough evaluation and documentation for the patient's medical record.

At first glance, the collaboration of Fakhry, a trauma surgeon, and Ford, an associate professor of pulmonary and critical care medicine, may seem odd, but at their core, the two disciplines have a strong common bond. "Both groups are in the business of taking care of people in situations where time matters," says Fakhry, professor of surgery and chief of the Division of General Surgery.

Roughly half of the 40,000 traffic fatalities occurring annually die at the scene of the accident, Fakhry says, but if you survive that, "your best chance for survival occurs within the first hour or two, what we call the ‘Golden Hour.' The focus in trauma care has always been to make sure you get the patient to the appropriate level of care in the shortest possible time."

To make matters worse, South Carolina leads the nation in the percentage of rural highway fatalities, according to a 2011 study. And, as Fakhry points out, all the state's trauma centers are in urban areas, where they are most needed. "It's an access issue, in a way," he adds, as rural hospitals try to save patients who may be far removed from the nearest full-service medical center.

Still, trauma patients have an advantage over sepsis patients because a hospital network already exists for victims of trauma-related incidents.

"The sepsis piece was actually appealing to these (participating) hospitals because there is already a trauma system in place for triage and transfer throughout the United States," Ford says. "There isn't a parallel system for people who have catastrophic medical illnesses, meaning usually respiratory failure or shock and other major organ system failures. So it becomes incumbent on the doctors and nurses at a hospital who have a very ill patient, to hunt down a place where they could have that patient transferred to if they're unable to support that patient's needs."

To counter that hurdle, Ford and Fakhry, armed with a grant from the National Institutes of Health, approached several rural hospitals in 2009 with a proposal to establish a telemedicine network linking MUSC to their emergency departments. It was a daunting task. Before any consultations could commence, MUSC staff had to obtain privileges at the participating hospitals, reams of paperwork had to be completed, and local Emergency Department staffs had to undergo training in the use of the telemedicine units, essentially laptops on wheels equipped with video cameras and microphones.

This was a marriage of convenience between two conditions that required really expert care at the very beginning, but in most cases presented at emergency departments those resources may not be available to provide specialist-directed care," Fakhry says. "You couldn't put an expert trauma surgeon and an expert critical care doctor in every emergency department, but with telemedicine, we could make that expertise available and make it affordable in these remote locations."

Of course, telephone consultations have been ongoing for years, and continue to be given daily. The difference in this program was the video component and data transmission as well as medical documentation.  "People do call us on the phone," Ford says, referring to rural hospital staffs seeking recommendations on difficult diagnoses.  "But from a patient care perspective, you cannot do the kind of evaluation that's necessary for a very sick patient. You can't give optimal recommendations because the patient evaluation is much more limited. The level of dialogue is much lower than if you're doing a true clinical consultation.

"There's a lot of variation in what you're told and what your assessment is once the patient actually arrives," Ford continues, "and sometimes it can result in decisions you would have done differently, but you just didn't know because you didn't have all the data before they got to MUSC. And for the people that came after we had that (telemedicine) consult, there was none of that. They showed up, we knew exactly what their status was, what their problems were, what had been done and what hadn't been done. It was a lot clearer picture."

Six MUSC trauma surgeons and four pulmonary/critical care physicians were available to consult with the rural hospitals 24 hours a day, seven days a week, 365 days a year. During the active phase of the program, participating hospitals requested 33 consults from MUSC, with approximately two-thirds of those sepsis-related.

Approximately half of the trauma patients involved in the program were transferred to MUSC, a statistic in which Fakhry took pride, pointing to the combination of care and cost-effectiveness. "I was able to take care of that patient with the doctor and the nurses, and the patient was able to go home from that hospital," Fakhry says.

By contrast, about 80 percent of the sepsis patients came to MUSC, perhaps owing to the insidious nature of the disease.

"Sepsis is rapidly progressive," Ford says.  "Someone can come in and say I've had a fever, shortness of breath and I've been coughing up stuff, and they can be in shock and on a ventilator within hours. It is very rapidly progressive. There were several patients who had what might have appeared to be relatively bland abnormalities in some of their laboratory tests. To me, as someone who's used to this kind of severely ill patient population, those are like little red flags going off in my head."

Although the project is wrapping up, Ford and Fakhry say they were pleased with the overall program and are looking ahead to similar individual outreach programs for the future. Ford would broaden her program to include a three-step approach: follow-up consultations beyond the initial contact; sharing patient safety and quality care with participating hospitals, and bringing an education component including all the disciplines involved with medical critical care.

Fakhry, for his part, believes improving technology in the telemedicine field will slice health care costs dramatically. "My wife uses her phone to do face-time with our grandchild in Washington," he explains. "My prediction is none of this fancy equipment is going to be needed. One day in the next few years, a doctor somewhere will want me to give an opinion. They will call me on the phone and say ‘I've got a patient in the Emergency Department, I'll just send him to you.' I'll say, ‘Let me take a look.'

They'll hold up their phone – I'll be able to see the patient, talk to the patient, interact with him, and we'll have a different way of doing things than before at much lower cost."


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