The following is not meant to be an exhaustive review of all applications, but rather a review of several important concepts designed to provoke the interested reader to examine new applications.
The University of California San Diego launched a pilot project to virtually bring in an ED physician for triage in the event of a major patient surge. The EDTITRATE study 35 was designed to solve the problem of wasted overstaffing versus the delay of arrival of an on-call back-up physician. During times of patient surges, the back-up MD is called in virtually. The on-call back-up physician meets the patient via telemedicine technology, with the support of an on-site ED-RN, and examines the ear, nose, and throat; listens to lung and heart sounds; remotely reviews laboratory and radiographic data; and either triages to higher expedited care or prescribes care and discharges the patient. Currently, the study is not completed but suggests a creative solution for the surge problem.
Avoiding Unnecessary Transfers
Brennan et al. 36 performed a comparative analysis of traditional face-to-face care with remote care to demonstrate that remote ED care can be performed from an urban to a rural ED without degradation of quality. In a unique cross-over fashion, they demonstrated equivalent quality of care, with similar 72-hour return rate, patient satisfaction, and a 10-minute shorter average ED length of stay with telemedicine. The implication is that urban ED overcrowding could be mitigated by telemedicine by reducing transfers from rural to urban settings.
A Houston-based effort called the Emergency Tele-health and Navigation project (ETHAN) 37 connects emergency physicians with EMS providers who are on scene with the intent of avoiding needless transports to the ED. The process includes real-time communications among EMS, physicians, and the patient. When summoned to see a patient, if the EMS judges the issue not urgent, a video link is established with an ED physician, and an evaluation is performed by an ED physician using a tablet, with the EMS provider performing vital signs and physical assessment under the direction of the remote physician. Early results suggest that up to 40% of EMS transports in Houston did not require acute care, but rather needed referral to primary care for their chronic conditions. 38 The ETHAN project was able to avoid unnecessary transport, ultimately reducing ED overcrowding and reducing wait times for those needing urgent care.
Extend Capabilities Outside the Local Emergency Department
The concept is to take advantage of the unique characteristics of EDs staffed 24/7/ 365 with physicians and advanced practitioners who possess a broad skill set (eg, general medicine, pediatrics, CCM, trauma, toxicology) and apply the specialty skills remotely outside of the specialty center or ED setting.
Emergency Department Consultations
Sophisticated or specialty centers can reach out to other less resource-rich institutions, extending the capabilities to the more remote ED. As far back as 1996, a Chinese university–based program established ED outreach to an offshore hospital in Taiwan. 39 During a 12-month period, they performed 275 consultations, including 24 specialist/subspecialists spanning more than 100 different members of the medical staff with a very high satisfaction rating. This type of program has been operational at the University of Maryland Medical System since February 2017.
Eastern Maine Medical Center 40 Tele-Emergency Department and Trauma Services connects more than 12 hospital centers to the main trauma center. Receiving over 800 patients per year with 50% from rural community hospitals, the program is able to consult immediately, avoid unnecessary transfers, and begin therapy within minutes rather than waiting hours to arrive at distant specialty centers for interventions.
In 2006, the University of Arizona Medical Center joined with the Tucson Fire Department and Tucson Department of Transportation (DOT) to develop a citywide EMS telemedicine system built around the DOT's mesh broadband wireless network. 41,42 At the hospital end there were workstations located in the ED and the “trauma room.” On the EMS vehicle, cameras were positioned both inside the ambulance and outside with a 360-degree pan capability with a 19-inch monitor for the patient or EMS personnel to see the remote trauma physician in real time. Although there were limitations to coverage and a full report was not published, the authors did describe remote assistance with endotracheal intubation when onsite providers used the video laryngoscope device Glidescope technology. 43
Correctional System Health Care
This area suffers from complexity of movement, security risks with prisoner transport, and major public safety issues if a detainee were to become violent or attempt to escape. The ACEP has nicely outlined the issues of correctional care in the ED. 44 As far back as 1997, telemedicine within the correctional system has been shown to be cost and medically effective while minimizing security risk of transport. 45 ED telemedicine programs can serve as an immediate resource for prison-related trauma or general emergency medical services.
A variety of industries and individual adventure travelers require emergency medical support in remote and often austere environments. There are both commercial and university-based providers of on-demand emergency care via telemedicine to oil, gas, aviation, maritime, and remote research stations. Medical support services may be provided directly to patients and in other cases a remote EMT, paramedic, nurse, or physician providing care in consultation with the remote physician. With 24/7 staffing, the ED may be the optimal provider.
Mobile Integrated Health Care with Direct Audio-Visual Patient Contact
Evolution Healthcare in Dallas has implemented an audiovisual connection with EMS providers who go into the homes of at-risk patients and provide a patient–physician real-time, live audio–video interaction. 46 The goal is to avoid EMS responses, ED visits, and medical inpatient admissions. The project has demonstrated a 19% decrease in ED visits per member per month (PMPM) costs, a 21% decrease in ED utilization, a 37% decrease in inpatient PMPM costs, and a 40% decrease in patient utilization (all reaching statistical significance) through this telemedicine-coordinated care program.
Bring Specialists or Capabilities into the Emergency Department from the Outside
“Tele-radiology is one of the oldest, most established, successful, and widely used clinical telemedicine specialties” 47–49 “with on-call emergency reporting being used in over 70% of radiology practices in the US.” 50 Teleradiology is of primary value to smaller hospitals with the inability to staff onsite radiologists. From the perspective of the ED physician, timeliness of reports is paramount. Distant radiologists must be available and work in real time to avoid delayed overreads that can be problematic once the patient has left the ED. 51,52 Currently there are no data regarding the penetration of teleradiology into the ED, but it is presumed high in otherwise uncovered facilities.
When considering the raw numbers of ECGs transmitted, next to teleradiology, telecardiology may be the second-most used remote technology to support ED physicians and patients. Telecardiology includes remote reading of ECGs, echocardiograms, pacemaker interrogation and monitoring, and review of angiograms. When looking at a prehospital review of electronically transmitted ECGs, there has been a shortened “door to balloon” time. 53 There is little information regarding the development of telecardiology networks as is seen in telestroke networks. Nor has there been much emphasis on the visual examination of the cardiac patient. Certain European programs have evolved to cloud-based 12-lead ECG computing, making the information available to a cardiologist via a handheld device. 54 The University of Maryland telemedicine program is currently providing remote support and management of congestive heart failure (CHF) patients with chronically implanted left ventricular assist devices (personal communication with program director).
It is recognized that tPA improves outcomes for nonhemorrhagic thrombotic stroke. The American Heart Association estimates that only 3% to 5% of patients eligible to receive tPA actually receive it. 55 With the desire to share risk in the administration of tPA, the ED physician may seek a qualified and emergent neurologic opinion. Silva et al. 56 in a Health Resources and Services Administration (HRSA)–supported national study was only able to identify 56 active telestroke programs in the United States as of 2012. Of the programs being interviewed, 100% provide ED consultations. All highlighted limitations or barriers to implementing or maintaining these programs, such as lack of reimbursement, need for state licensure, and lack of sustained funding. Therapeutically, telestroke programs can lead to use of tPA in greater than 50% of the eligible candidates, dramatically better than those without telestroke. 57 Due to remote geographic sites, the shortage of neurologists, and the relative paucity of telestroke systems, stroke patients in rural areas are 10 times less likely to receive timely administration of tPA. 58 Of note, the visual examination of the stroke patient was felt to be important and improved the accuracy of diagnosis.
According to the World Health Organization and the American Hospital Association (AHA), 59,60 neuropsychiatric illnesses are now the number-one cause of disability. As many as 40% of ED patients may have a mental illness, with mental illness being the fastest-growing component of emergency medical practice. 61 To confound the situation, the AHA has reported a growing shortage of psychiatrists and mental health care workers in general. The American Psychiatry Association believes that video-based telepsychiatry helps meet patients’ needs for convenient, affordable, and readily accessible mental health services, leading to improved outcomes. 62 In 2009, ED telepsychiatry was rare, with only three recognized programs. 63 More recently in 2011, the ACEP 64 reported results of a statewide telepsychiatry program managing ED psychiatric patients. Six thousand patients seen by telepsychiatry in the ED were compared to equal numbers of patients in nontelepsychiatry EDs. Admission rate was reduced 30% (from 12% to 8%), 30-day outpatient follow-up was increased 36%, and both Medicaid and private payors received smaller bills. By 2015, the South Carolina Department of Mental Health 65 reported that daily telepsychiatry visits had increased from 8.7 to 14.7 during the period 2010 to 2015, and ED length of stay (LOS) had dropped from approximately 48 to 72 hours to 8.5 hours. In telepsychiatry programs, the visual evaluation of the mentally distressed or ill was generally felt to be significant.
Tele-ICU in the Emergency Department
Little is written about tele-ICU in the ED, perhaps because the ED is staffed with physicians trained in acute care and critical illness. There is an increasing interest among ED physicians to continue critical care until the patient actually leaves the ED. 66 The growing concept is that the ED intensivists (EDIs) would staff an ED-ICU. This concept could simply provide an expansion of coverage of a larger resuscitation bay or more bays. A lexicon has developed surrounding the ED-ICU adopted from Weingar et al. 66 :
Emergency medicine critical care—subspecialty of emergency medicine focused on care of the critically ill in the ED
EP intensivist—a physician who has completed a residency in emergency medicine and a fellowship in critical care.
ED critical care—emergency medicine critical care practiced specifically in the ED
ED-ICU—unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU
RED-ICU—hybrid Resuscitation unit in the Emergency Department providing ICU care
If the concept of a second set of eyes is valid, then the application to the ED tele-ICU is logical and would be a mechanism to smooth transition from the ED to the ICU or to provide comprehensive intensive care in the ED in the event of a patient surge.
Telesupervision of Advance Practice Providers
Appropriate distribution for trained human resources in emergency care is a challenge across the United States, but especially in rural areas. Advanced practice providers (nurse practitioners [NPs] and physician assistants) help meet provider needs, but often require consultation with a supervisory physician. Since 2003, the University of Mississippi has been providing trained NPs working in rural EDs remote supervision and collaborative consultation via telemedicine. 67 A decade later Summers et al. 68 reported that the program had expanded to 19 rural hospital EDs, with each NP seeing approximately 200 patients per month. The parent program had conducted over 400,000 teleconsultations (about 40% of patient encounters). Of the patients seen by acute care practitioners, 57% were discharged from the ED and 21% were transferred to a higher level of care. General satisfaction was high, with 93% of patients comfortable or very comfortable with the telemedicine system, 98% could see and hear the remote physician well, 85% rated the combined NP with remote physician care as good or excellent, and 91% said they would return because of the telemedicine system.