Memorandum by the Queen Victoria Hospital
NHS Foundation Trust (MT 10)
1. SUMMARY
1.1 The Queen Victoria Hospital NHS Foundation
Trust (QVH) in East Grinstead is a tertiary acute centre receiving
a significant number of acute trauma calls from hospital A&E
Departments and Minor Injuries Units (MIUs) in the South East.
A Telemedicine system has been developed by the QVH over recent
years, which enables referring hospitals to transmit images and
clinical information in a secure manner to the QVH to facilitate
informed discussion between clinicians at both sites in order
to assist the clinical decision making process. The system has
also been extended internally within the Trust and now offers
a central repository for all clinical images taken by the Photographic
Department.
1.2 Few telemedicine projects in the UK
have progressed from pilot study to mainstream activity. At QVH,
we have followed a common sense approach of implementing a practical
simple system, keeping the system with clinicians and IT support
staff, enabling users to drive the system, and maintaining consistent
support. We believe these are the reasons why our system has been
welcomed by clinical staff at the QVH and external locations and
is becoming increasingly accepted as part of the Trust's trauma
management processes.
1.3 We believe that the tele-medicine facility
at QVH will play an integral role in future service development
at the Trust. In particular, the facility strongly supports the
establishment of the QVH burns unit as a UK Burns Centre. The
ongoing National Burns Care Review is currently reviewing this
decision.
2. INTRODUCTION
2.1 The QVH is a specialist acute unit providing
services in plastic surgery (including burns and hand surgery),
maxillofacial and corneo-plastic surgery for a wide catchment
population across the South East. The Trust is one of the UK's
largest plastic surgery units and has one of the most advanced
Burns Units in the UK.
2.2 QVH employs Consultant staff in the
specialties of Plastic Surgery, Maxillofacial Surgery, Orthodontics,
Ophthalmology and Anaesthetics, together with Radiology and Pathology.
The Trust also provides a range of medical services including
Rehabilitation and Elderly Medicine for a more localised community
under the management of a Trust Consultant Physician, with a number
of inpatient beds being managed under the care of local GPs. A
further range of services is provided by several visiting Consultants
in specialties which include Cardiology, Dermatology, General
Surgery, Gynaecology, Orthopaedics, Paediatrics, Respiratory Medicine
and Urology.
3. TELE-MEDICINE
AT QVH
3.1 Tertiary referrals from other sites
The Trust receives substantial numbers of tertiary
referrals from other sites with regard to its specialist services.
A large volume of trauma referrals are received from A&E Departments
and Minor Injuries Units situated throughout Kent, Sussex and
Surrey. The Trust receives around 100 such calls every week in
respect of acute plastic surgery services. The management of trauma
referrals (both complex and simple) has been complicated in the
past by the fact that the type of injuries concerned such as burns
or hand trauma can be particularly difficult to describe over
the telephone. This has led to situations occurring where patients
have been transferred to the QVH on the basis of a verbal description
of an injury, but following examination on arrival at the hospital,
the priority of the referral can be seen to be very different.
This change in priority can be both upgrading and (more commonly)
downgrading the urgency of intervention or treatment. Use of the
Trust's Telemedicine facility now means that almost 20 A&E
Departments and MIUs are able to send photographic images of injuries
which can be reviewed immediately by specialist staff at the QVH
and can therefore assist in the clinical decision making process.
The development of the Telemedicine Service is summarised in the
following section.
3.2 Development of Telemedicine at the QVH
The Telemedicine project was initially established
in 1999, and involved three local A&E Departments which regularly
referred patients to the Trust. A digital camera was provided
for each of these, together with associated training and support.
Digital images were then taken of appropriate trauma cases and
these were sent to the QVH as email attachments. This early approach
was generally successful and additional sites began to be included.
After a relatively short time, however, a number of shortcomings
began to emerge, including the following:
3.2.1 Firstly, although the emailed
images were being sent via the NHS network, neither encryption
nor added form of security was being employed which restricted
the amount of accompanying data which could be sent. Moreover,
the photographic images themselves were often of an identifiable
nature (eg facial).
3.2.2 Secondly, a number of technical
problems frequently emerged regarding the ease of use of the system.
For example, email attachments were sometimes received in an indeterminate
format, which then needed to be converted to an appropriate format
before they could be viewed.
3.2.3 The Trust therefore took the decision
to commission the development of a bespoke Telemedicine system,
which would be both easy to use and meet appropriate security
requirements. The Distar (standing for Digital Storage and Retrieval)
system was therefore produced by GCP Systems and was implemented
within the Trust towards the end of 2000. The system has two distinct
elements, the first of which is client based and as such, is installed
within A&E Departments and MIUs of referring hospitals. The
second is the host software, which takes the form of an internal
web page at the QVH. Staff within referring Departments take photographic
images of appropriate cases and then send these to the QVH via
an easy-to-use five step process which results in the appropriate
images being selected, encrypted and then transmitted securely.
Since the entire message including the images is encrypted before
transmission, identifiable details of patients can be included,
together with confirmation of patient consent. The host software
at the QVH incorporates a facility which checks for the arrival
of incoming emails containing photographic images, decrypts them
on receipt and then posts them to the internal Telemedicine website,
where they can be viewed immediately by staff with the appropriate
level of authorisation to do so.
3.2.4 During the development of the
system, it became apparent from an early stage that a Clinical
Coordinator was required to promote the system both internally
and externally, and to train staff in its use. The first two Clinical
Coordinators had extensive experience as junior doctors within
the Trust, and were therefore ideally suited to train staff in
the use of the system, both within the trust) and at other hospital
sites. A permanent Clinical coordinator has since been appointed.
As a qualified nurse, his experience greatly assisted the process
of dealing with other clinicians and provided an invaluable link
to non-clinical support staff especially in IT to facilitate prompt
troubleshooting.
3.3 Results from Tele-Medicine at QVH
3.3.1 Access to Images
Since the Telemedicine (and digital
photographic) system has been introduced, a substantial number
of changes have occurred in the management of clinical activity.
For example, the trauma board in the theatre complex has had a
wall mounted computer installed. This allows surgeons to communicate
more objectively with each other when planning interventions,
and allows junior surgeons to gain valuable feedback from senior
colleagues. Similarly computers have now been located within outpatient
consulting rooms, thereby enabling clinical staff to access images
during patient consultations. The system has a number of features
to assist these processes; for example, by entering the unit number
of a specific patient, the system will display thumbnail images
of all photographs taken. Clicking on any one of these thumbnails
displays the full image for enhancement and viewing.
3.3.2 Proof of Effect
We have conducted several large studies.
In 2002 we looked at the use of the system over 10 weeks, covering
almost a thousand patients. The system was found to be simple
and easy to use. In 2003 we looked at similar number of patients
and found a significant difference in the way we managed their
cases. Fewer patients needed to come to the Queen Victoria Hospital
for an extra assessment after the phone referral (6.5% decrease)
and more patients could be booked directly to the day surgery
unit (10.5% increase). The decision to refer a patient from the
non specialist to the specialist is rarely inappropriate, but
gauging the urgency of intervention or review is fraught with
difficulty and miscommunication. The accuracy of triage was assessed
on arrival at the Queen Victoria Hospital, and was found to be
significantly improved. This appears to be due to the extra information
provided by the objective digital image.
3.4 Cost considerations
The cost of the system has not been recouped
by extra income to the Trust, since the National Tariff does not
allow for an activity of "providing specialist opinion"
if the patient is not admitted, and hence the costs of providing
such an advice service are unlikely to be covered. This could
be considered an overhead on the cost of those who are admitted
but puts a Trust offering this service at a financial disadvantage
compared with those who do not. As we await the impact of the
new tariff arrangements for surgical episodes, the use of a telemedicine
system to increase the accessibility of the surgical service is
likely to be one tool to increase the efficiency of a surgical
unit, thereby allowing a greater number of patients to be treated.
The lack of financial benefit has been shown consistently elsewhere
in a variety of health care environments, including Australia,
Canada, the USA and Europe.
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