Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment

The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.


Introduction
There is a critical global shortage of healthcare professionals. As a consequence, qualified professionals may not be physically present particularly in under-resourced regions, and providing quality healthcare may be quite challenging. This challenge can be tackled by providing specialist medical services using information and communication technologies to remotely located healthcare workers and patients where such expertise is not immediately available. This is known as telemedicine. In telemedicine, the client is separated from the expert in space [1]. The concept of telemedicine has been used in one form or another for centuries. Smoke signals were used in ancient African villages to alert adjoining villages of disease outbreaks, and bonfires were used to warn of bubonic plague in the Middle Ages in Europe. With advances in telecommunication, newer systems such as the telegraph were used to transmit medical information about epidemics and war casualties. However, the use of telemedicine was facilitated by the invention of the telephone in the nineteenth century. This culminated in one of the earliest recorded uses of information and communication technology (ICT) in telemedicine, when Einthoven, on 7th February 1906, transmitted electrocardiogram (ECG) tracings over telephone lines [2]. By the 1930s, medical information was being transmitted from remote regions of Australia and Alaska to specialist medical centres. With the invention of the television in the 1950s, advances in closed-circuit television and video conferencing led to the adoption of telemedicine in patient monitoring and consultations [3]. Perhaps, the earliest implementation of modern telemedicine was by the National Aeronautics and Space Administration (NASA) in the 1960s when it was used for remote physiological monitoring of astronauts during manned space flights [4]. NASA continued to play a pivotal role in the development of telemedicine with the development of the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project on the Papago Indian Reservation in Arizona, USA, in 1972. The STARPAHC project included a van equipped with an X-ray machine and other medical instruments, and it was staffed by two paramedics. The van was linked by two-way microwave transmission to the Public Health Service Hospital complemented by a remotely located clinic staffed by a physician assistant linked to the control centre in the hospital [5]. After the December 1988 earthquake disaster in Armenia, NASA established the first international telemedicine project known as the Spacebridge to Armenia that allowed telemedicine consultation between medical centres in the United States and Armenia [6]. By the 1970s, the National Library of Medicine funded research into the reliability of telemedicine via satellite communication to 26 sites in Alaska, USA. Improvements in telecommunications technology have led to advances in network infrastructure that enabled the development of high-definition live interactive video-to-video networks such as the European Union-funded LiveCity project. These, in turn, have led to increased telemedicine use over the past 40 to 50 years with a subsequent increase in research since the 1990s.
Telemedicine potentially holds great promise in facilitating emergency medical practice. It is increasingly being used in emergency medicine with an associated increase in published research. It is particularly suited to medical emergencies where treatment delays adversely affect clinical outcome. A typical scenario is ST elevated myocardial infarction (STEMI) where recognition of ECG changes by paramedics could facilitate early intervention and improve clinical outcome. However, recognition of ECG changes of STEMI by paramedics appears to be suboptimal [7], and adverse clinical events that occur during pre-hospital transportation [8] may also benefit from realtime clinician advice. Paramedics in ambulances have used telemedicine links with specialists to facilitate pre-hospital diagnosis and reduce treatment delays in stroke, myocardial infarction, and trauma. Telemedicine has also been used by emergency medicine doctors to supervise remotely located nurse practitioners and general practitioners in minor injury clinics [9]. This literature review is part of the emergency use case of the LiveCity project and analyses published studies to highlight the use of telemedicine in pre-hospital care.

Methods
We performed an automated electronic search using the MeSH terms identified in Medline. The terms included the following: Telemedicine, Telecare, Telehealth, Teletrauma, Telestroke, eHealth, mobile Health, Pre-hospital care, and emergency care. The search terms were used as keywords on Medline, Excerpta Medica Database (EMBASE), Cochrane Database of Systemic Reviews (CDSR), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search was then finalized using Boolean operators to combine ('OR') and cross-reference (' AND') between domains. The first ten pages of a basic web search using the Google search engine were analysed for relevant articles. A manual search was done by checking reference lists of selected articles and researching key authors.
Abstracts were independently reviewed by two of the authors, and the full text of articles that met the inclusion criteria were retrieved for further analysis. Included studies were collated and critically analysed based on their methodology and sample size to summarize their results.
Studies carried out between 1970 and 2014 that addressed telemedicine use in the emergency care of trauma, myocardial infarction, and stroke and studies whose outcomes included cost-effectiveness, feasibility, and clinical outcome were included in the review. Case reports and studies that were not published in English and did not address an aspect of emergency medicine were excluded from this review.

Results
The initial literature search yielded 1,279 studies. Based on the inclusion criteria, 1,240 were excluded, while 39 were selected for further analysis. Twenty-five of the studies focused on stroke management, while five and nine were on myocardial infarction and trauma, respectively.
We found eight articles that were feasibility studies, while six articles explored the reliability of telemedicine. Four articles addressed the diagnostic accuracy of telemedicine, and three articles explored the use of telemedicine to reduce treatment delays. Thirteen studies used the 'Hub and Spoke' model, while five of the studies used a link between an ambulance and a hospital. Twenty-one of the studies reviewed did not clearly define the model used. Table 1 shows the characteristics of the studies included. We found 2 randomized controlled studies, 10 casecontrol studies, and 27 observational and descriptive studies (1). The network types used in the studies were the following: mobile broadband in 8 and wired broadband in 31 of the studies included. The methodologies and subjects of the studies reflect the nascent nature of research in this field. Early studies address the feasibility, accuracy, and reliability of telemedicine use in clinical settings which have not been fully addressed due to design flaws identified in Tables 2, 3, and 4.

Discussion
There has been an exponential growth in the number of telemedicine articles published since the mid-1990s. This review noted the highest amount of research into telemedicine use in stroke care. Trauma and myocardial infarction have seen much less telemedicine-related research.

Stroke
Telemedicine in stroke management has undergone the most extensive study of all areas examined. Its use is feasible [10,11] but dependent on the technical performance of the telemedicine equipment and broadband infrastructure [12,21]. Due to its novel uses, medico-legal concerns have led to questions about the relevance and clarity of communication during informed consent. However, analysis of video-taped telemedicine consultations of acute stroke patients before intravenous administration of tissue plasminogen activator showed that 80% of observers rated informed consent as adequate [23]. Administration of tissue thromboplasminogen activator (tPA) within 3 to 4.5 h [49][50][51] of an acute ischemic stroke remains the gold standard in its management. However, this approach is restricted by time constraints and requires the supervision of a clinician with expertise in stroke management, and as a result, there is a disappointingly low utilization of thrombolysis in ischaemic stroke [52,53]. Where available, integrating stroke specialists in pre-hospital stroke response teams significantly reduces time to treatment [54]. This is however not possible in a large proportion of locations where there is a limited availability of stroke specialists. Remote access to a stroke specialist is now possible, and recent studies comparing in-person consultation with remote consultation suggest that telemedicine is a promising solution to the lack of local expertise. The National Institute of Health Stroke Scale (NIHSS) assessment of stroke patients using telemedicine is as reliable as face-to-face assessment [20]. And radiological review of brain CT in stroke management is both feasible and reliable [34]. In the 'hub and spoke model' , under served areas where stroke management expertise is lacking (i.e. spoke), telemedicine provides an ideal opportunity for supervision by a centrally located stroke expert (hub). Analysis of clinical outcomes of patients managed using this model suggest that although there is increased consultation, the quality of care remains similar and there was no statistical difference between telemedicine and face-to-face consultation, in short-term [14,15] and long-term [25,26] mortality. In the context of budgetary constraints, a cost-effectiveness analysis indicated that telemedicine is more expensive than usual care [16] partly due to high upfront equipment cost. However, there is the potential for significant cost savings due to reduced length of hospital stay [55].

Trauma
The effects of telemedicine on trauma management have not been as widely studied as in stroke, in the emergency medical services. Telemedicine has been deployed in major disasters such as the Armenian earthquake disaster in 1988. It is well suited to the management of major incidents where an acute deficit of healthcare professionals can be ameliorated by teleconsultation [56]. Where local expertise is lacking, teleradiology has improved diagnosis and reduced expensive transfer of trauma patients [57]. Analysis of the impact of telemedicine on emergency medical services suggests a reduction in mortality and hospital cost [40]. In a hub and spoke model of a central burns unit and three peripheral hospitals, telemedicine use led to increased consultation, but burns assessment was as accurate as face-to-face assessment and reduction in transfers to burns units led to significant cost savings [41]. Interestingly, paramedics that were guided by an emergency medicine clinician could obtain interpretable focused assessment with sonography for trauma (FAST) ultrasound [42], recognize key physical signs, and make better management decisions [43]. The use of a telemedicine    Prospective observational study comparing stroke thrombolysis in regional hospitals remotely supervised over a telemedicine link with thrombolysis in academic stroke unit 115 patients were treated in the regional hospitals, and 110 were treated in the stroke centres. The rate of IV-tPA was higher in stroke centres compared to regional hospitals although the quality of care was similar in both groups Larger sample size is required to confirm the conclusions in this study Ang  Observational study analysing the effectiveness and safety of a telestroke programme in a rural area with a high elderly population 53 patients were recruited to the study over a 16-month period. Outcome was worse than those in the published studies but the average age of this study group is much higher than those in other published data Sample size is small, and study design does not allow clear conclusions from the study Demaerschalk et al. [34] Stroke 2012;43:3098-3101 Smartphone teleradiology application is successfully incorporated into a telestroke network environment Case-control study assessing the reliability of smartphone-based CT interpretation by comparing it with PACS-based system 53 patients were recruited. There was an agreement (95% CI) between smartphonebased and PACS-based systems, suggesting that smartphone based systems are a reliable alternative This study compares the interpretation by neurologists on smartphone with radiologists on PACS system, introducing a possible bias based on different specialties. Like-for-like comparison may be required to validate their study  referral in an acute burns unit led to a reduction in admission that could reduce hospital costs [45].

Myocardial infarction
The ideal recommendation for reperfusion of STEMI is within 2 h of first medical contact [58]. The requirement for urgent management of patients with myocardial infarction can be facilitated by the use of telemedicine for diagnosis and treatment. Efforts to shorten treatment delay are crucial, and various studies have been published addressing this challenge. Patient transfer directly to percutaneous coronary intervention (PCI) laboratory after pre-hospital diagnosis of STEMI in a telemedicineequipped ambulance reduced treatment delay [35,36] and reduced mortality from myocardial infarction [59].
To expedite reduction in treatment delay, accurate ECG diagnosis of STEMI remains crucial. Currently computer [60] and paramedics [7] ECG interpretation are not reliable enough to enhance patient triage for urgent PCI.

Conclusion
This review found limited conclusive studies for the effectiveness of telemedicine in emergency medicine. The best evidence is in stroke management where conclusive evidence of the significant positive effect of telestroke on clinical outcome has led to its recommendation for stroke management. Telemedicine appears to have a significant impact on the quality of ECG interpretation, but there is as yet no conclusive evidence that telemedicine affects clinical outcome in myocardial infarction. We could find very few studies that critically analysed telemedicine use in the pre-hospital care of trauma. Studies have demonstrated that burns assessment using telemedicine was as accurate as face-to-face assessment. The proliferation of smartphones, tablets, and other mobile electronic devices creates an opportunity to extend standard professional health care particularly in medical emergencies where urgent intervention could reduce mortality and improve quality of life. Telemedicine could enhance emergency medical services by helping expedite urgent patient transfer, improve remote consultation, and enhance supervision of paramedics and nurses.
However, in order to regulate and standardize practice, more research is required. Particular emphasis should be on better study design and larger sample size to improve the reliability of results and conclusions. A large proportion of the studies analysed focused on ambulance mounted equipment. Wearable technology such as headmounted displays that will allow paramedics reach patients in situ may improve early pre-hospital diagnosis and should be investigated. To further reduce response times, consideration should also be given to incorporating smartphone technology into emergency systems and thus facilitate patient or bystander incident reporting. Although technological advances will continue to outpace their utilization in clinical practice, incorporating emerging technologies into medical practice holds promise in improving care and enhancing clinical outcomes, and researchers must continue to evaluate the effectiveness of telemedicine so that communication technologyassisted care is optimized.