Impact of an ultrabroadband emergency department telemedicine system on the care of acutely ill patients and clinicians' work

Objectives: To evaluate whether introduction of an emergency department (ED) telemedicine system changed patient management and outcome indicators and to investigate clinicians' perceptions of the impact of the system on care provided and on their work. Design: Before-and-after study of use of the Virtual Critical Care Unit (ViCCU), which uses an ultrabroadband connection allowing real-time audiovisual communication between clinicians at distant sites. Semi-structured interviews were conducted with medical and nursing staff at the end of the study. Participants and setting: The ViCCU intervention commenced on 1 January 2004. Our study was conducted in the EDs of an 85-bed district hospital and a 420-bed metropolitan tertiary hospital. It involved all acutely ill patients requiring urgent care (defined by triage category and grouped into critical care, major trauma and moderate trauma) who were treated during the 12 months before (n = 169) and 18 months after (n = 181) the intervention at the district hospital. Thirty-one of 33 clinicians (doctors and nurses) participating at the two hospitals took part in interviews at the end of the study. Main outcome measures: Changes in patterns of management (disposition [admission, discharge or transfer], treatment times, number of procedures) and outcomes (rapid acute physiology scores, hours on ventilation or in intensive care, length of stay). Results: Patient disposition remained unaltered for major trauma patients. For critical care patients, admissions fell significantly (54% to 30%), transfers increased (21% to 39%), and more procedures were performed. For moderate trauma patients, discharges increased significantly (45% to 63%), transfers decreased (48% to 25%) and treatment times were longer. No significant changes were found in outcome indicators. Clinicians reported that the ViCCU allowed greater support to remote clinicians. Specialists reported increased workloads and feelings of greater responsibility for patients at the district hospital. Nurses at the district site reported reduced stress, but district doctors reported some loss of autonomy. Conclusions: The ViCCU appears most effective for moderate trauma patients, with associated reductions in admissions and transfers. Large-scale trials of telemedicine systems that include measurements of both patient care and impact on clinicians' work are required.