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Telepresence in a Level 1 Trama Center

Telepresence in a Level 1 Trama Center

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A study suggesting that telepresence of a remote trauma surgeon could be useful and functional in a trauma setting, with the potential to address staffing shortages in rural and urban trauma care during mass casualty or disaster scenarios.
A study suggesting that telepresence of a remote trauma surgeon could be useful and functional in a trauma setting, with the potential to address staffing shortages in rural and urban trauma care during mass casualty or disaster scenarios.

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Published by: Telepresence Options on Apr 08, 2013
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Usability of Telepresence in a Level 1 Trauma Center 
Carl Ivan Schulman, MD, PhD, MSPH, FACS,Antonio Marttos, MD, Jill Graygo, MA, MPH, MDEd,Paul Rothenberg, BA, Gabriel Alonso, Shannon Gibson, PhD,Jeffrey Augenstein, MD, PhD, and Elizabeth Kelly, MAWilliam Lehman Injury Research Center, Division of Trauma and Surgical Care, University of Miami Miller School of Medicine,Miami, Florida.
 Abstract
Objectives: 
Limited resources and the diminishing physician work- force in trauma require unique and innovative solutions. Our hy- pothesis is that telepresence by a remote physician is an appropriate application in an urban trauma setting. The purpose of this study isto assess user satisfaction and usability of a mobile telemedicine robot in trauma care.
Materials and Methods: 
A usability study of  trauma patient assessments utilizing the Remote Presence-7 (RP-7)robot (InTouch Health, Santa Barbara, CA) with real-time, two-way communication between remote and local physicians was conducted at a Level 1 trauma center. Usability and acceptability was measured using survey questionnaires, open-ended feedback, and general ob-servations. Comparisons were made between remote and local phy-sician responses.
Results: 
One hundred fourteen patient encountersutilizing telepresence were performed. Remote and local physiciansexpressed a high level of satisfaction with the mobility (92% and 79%, respectively), communication (97% and 90%, respectively),and visual abilities (91% and 97%, respectively) of the RP-7 robot  for remote consultation purposes. On average, 89% of remote and local physician participants rated their overall telemedicine experi-ence as ‘‘excellent’or ‘‘above average.’’ 
Conclusions: 
This study suggests that telepresence of a remote trauma surgeon may be auseful and functional adjunct in the trauma setting. Further devel-opment of these technologies could mitigate current and future concerns about gaps in rural and urban trauma care and critical care staffing shortages and during mass casualty or disaster scenarios.
Key words:
robotic surgery, telemedicine, telesurgery, technology 
Introduction
T
his study evaluates physician acceptance of the RemotePresence-7 (RP-7) mobile unit (InTouch Health, SantaBarbara, CA) for use in a Level 1 trauma center. The RP-7mobile unit presents a unique technological innovationconsisting of a fully capable bidirectional communication systemhoused in the robot itself and a control station through which phy-sicians can remotely monitor, interact with, and communicate withpatients and on-site medical staff. The RP-7 provides real-time, se-cure, bidirectional video and audio feed. This technology has nu-merous potential uses in the delivery of medical care in general andcan provide access to care, consultation, and training that are des-perately needed in the today’s trauma care environments. The RP-7links on-site clinicians with remote physicians who can provideparticular expertise that would not otherwise be available on-site inthe timely manner required in trauma care.It has long been acknowledged that there are multiple challengesconfronting the trauma profession and trauma care delivery in theUnited States.
1
Current dissatisfaction with trauma as a surgicalresidency rotation and a career choice is on the rise. Residents aregenerally dissatisfied because of nonoperative care duties and thestructure of trauma rotations, whereas career trauma surgeons suffer from burnout and stress as a result of in-house call, night shifts,heavy workloads, and insufficient income. As a result of these andother factors such as the increase in the general and elderly popu-lations, it is predicted that by 2020, there will be a 6% deficit of surgeons in the United States.
2
Furthermore, it has been argued thatby the year 2020, the critical care sector will be unable to provideeven the current level of care let alone increase the amount of in-tensivists staffed.
3
The main priority of trauma clinicians is to achieve timely assess-mentanddiagnosisofallincomingpatients.Anydelayinbothpatientassessment and physician response can result in lost opportunities toimprove patient outcome and can result in increased morbidity andlength of stay.
4
The increased concern over future intensivist staffinghasledtoproposalsforalternativessuchasuniquestaffingparadigms,the regionalization of critical care, and the increased use of techno-logical innovations such as telemedicine applications.Early telemedicine studies have documented successes and im-provement in patient care, particularly in relation to improved andearly triage of severely injured patients, decreased rate of unneces-sarypatienttransfer,andimproved communicationfromgroundandair ambulance providers. The application of telemedicine has beenexplored in a growing number of medical specialties, from derma-tology to psychiatry, over the last three decades.
5,6
Only in the lastfew years has telemedicine been applied to trauma, critical care, andemergency surgical specialties.
7,8
The integration of telemedicine into the trauma environment ex-tends the reach of the trauma care specialists beyond the limits im-posedbytimeanddistance.Thisstudyhypothesizesthattelepresenceis a useful and acceptable technology for an experienced traumaphysician to successfully participate in the assessment and care of atrauma patient from a remote location.
248 TELEMEDICINE and e-HEALTH
APRIL 2013 DOI: 10.1089/tmj.2012.0102
 
Materials and Methods
 A prospective study of the usability of telepresence for conductingtraumapatientassessmentswasperformedinaLevel1traumacenter.Perceptions of appropriateness and usability were obtained fromboth the local and remote physicians using survey data collectionduring 114 trauma teleconsultations performed over a 16-monthperiod in 2008–2009. Our sample size was limited to patients whopresented when remote physicians who had completed full trainingcoursesonuseoftheRP-7technologywereavailabletoparticipateinthe survey. These cases were presented from the trauma resuscitationunit or an operating room at our Level 1 trauma center; however, theremote physicians accessed the RP-7 robot from multiple locations(from home, office, and/or the stationary telemedicine control cen-ter). Local physicians consisted of attending, fellow, and residentphysicians. The one exclusion criterion set forth for this study wasthat the remote physician had to be a trauma surgeon on staff withour facility; therefore telemedicine deployment and case selectiondepended on the availability of such remote physicians who wereable to take the time to participate in the study.For this study, we utilized the RP-7 system (
Fig. 1
). The RP-7 is amobile robotic communications platform that enables a physician tohave remote access to the hospital from the home, office, or any remote location where Internet access is available. The system iscomposed of the Control Station and the RP-7 robot (operating on an802.11 Wi-Fi network), which are linked via the Internet over a se-cure broadband connection. Using high-quality audiovisual com-munications equipment integrated with robotic mobility, the RP-7allowsphysicians to remotely interact with other clinicians as wellasto monitor the patient. The RP-7 is also equipped with a full tilt, panand zoom camera that allows the remote physician to focus on areasof interest or to zoom out to get a wide shot of the trauma bay. Onceconnectedwiththeconsultationsite,thelocalphysiciansdonothaveto be physically present to assist the robot or the remote physician asthe mobility, video, and audio transmit continuously and can all becompletely controlled from the remote Control Station. Remotepresence, therefore, allows a physician to be virtually present andunassisted in the trauma resuscitation area or the trauma intensivecare unit. Activationofthetelepresencesystemoccurredoncethecenterwasnotified by emergency medical services of an incoming trauma. Theremote physician accessed the laptop Control Station from which heor she could control both the movement and audiovisual commu-nication applications of the robot. Once the patient arrived in thetrauma bay, the remote physician performed the assessment along-side the locally present doctor, who generally began by relayinginformation given to him or her by emergency medical services re-garding patient status and injury details. The remote physician de- veloped his or her patient note based on the pictures, vitals, anddiagnostics viewed through the RP-7. The remote physician was alsoable to ask questions of staff in the trauma bay.Inordertoassessusabilityofthetelepresencesysteminthetraumabay, surveys were administered in real time to both local and remotephysicians. The usability survey forms varied somewhat, with theremote physician survey having 13 additional questions. The 5-pointLikert scale survey questions addressed three issues: (1) equipmentfunctionality (primarily visuals, communication, and mobility), (2)user satisfaction, and (3) qualitative feedback. Once the data wereacquired,afrequency distributionanalysiswasperformed.Datawerecompared using a
-test for proportions with significance at the 0.05level. This study was approved by the University of Miami’s In-stitutional Review Board.
Results
FromApril2008 toJuly2009,114 teleconsultations withtheRP-7robot were conducted at our Level 1 trauma center. The RP-7 robotwas deployed primarily in the resuscitation unit (95%), with six de-ployments in the operating room (5%). Of the patients evaluated, themajority suffered from blunt trauma (64%), followed by penetratingtrauma (29%), burn trauma (4%), and non-trauma injuries (3%). Inorder to assess usability, remote and local physicians were givensurveys to complete following each teleconsultation. From the 114teleconsultations conducted, 114 surveys were completed by remotephysicians and 62 by local physicians.Evaluation of the visual component demonstrated that remotephysicians on average were able to see the patient well (94%), to seethe local staff well (97%), to see all of the patient’s injuries clearly (92%), to see the screens and monitors presenting patient informa-tion/vitals (98%), and to see x-rays and other diagnostic tests clearly (96%). Additionally, 91% of remote physician respondents agreedthatthepicturerelayedbytheRP-7robotwas‘clearandcrisp.Localphysicians reported similarly positive perceptions of the RP-7’smechanical performance. They reported that the picture they viewedon the RP-7 robot was clear and crisp (97%), and they reported thatthey were able to see the remote physician well (98%).Perceptions of communication quality were relatively high for remote (97%) and local (90%) physicians. However, there was asignificantdifferenceinexperiencedcomfortlevelswithtelepresencecommunication between local and remote physicians. Remote
Fig. 1.
The Remote Presence-7 robot in use during surgery.
TELEPRESENCE IN LEVEL 1 TRAUMA CENTER
ª
MARY ANN LIEBERT, INC.
VOL. 19 NO. 4
APRIL 2013
TELEMEDICINE and e-HEALTH 249
 
physicians consistently had a more positive view of the RP-7’scommunication abilities (
Table 1
). Whereas 79% of local physiciansfelt comfortable communicating with the remote physician, 98% of remote physicians felt comfortable communicating with staff duringthe consultation (
 p
<
0.001).Similar differences in perception between remote and local phy-sicians were found in relation to questions on mobility. For example,79% of local physicians felt the robot did not interfere, whereas 92%of remote physicians felt the robot was unobtrusive (
 p
<
0.025).Likewise, remote physicians (98%) were more likely than local phy-sicians (84%) to feel that the robot appeared to maneuver effectively (
 p
<
0.001).In terms of general satisfaction and comfort with telemedicinetechnology, remote physicians had a more positive perception usingtheRP-7robot(
Table2
).Bothsetsofphysicianswereaskedquestionsabout their future preferences and overall experience with the RP-7robot. Seventy-five percent of local physicians agreed that ‘‘In thefuture, I would like to have the ability to participate on patient casesfrom a remote location as a standard operating procedure.’Ad-ditionally, 70%oflocalphysicians and98% ofremotephysicians feltthat a telephone alone would not have been as effective as tele-presence. In general, overall perceptions of their experience with theRP-7 robot were positive among both physician populations (
Fig. 2
).
Discussion
Technological advances have provided innovative solutions for medical care, particularly in time-sensitive settings such as emer-gency departments and trauma centers. The busy nature of thetrauma center or the complex injuries often requires consultation or communication with a specialist who may not be immediately available. It is at these crucial times that robotic telepresence, whichcan connect a local physician with a remote physician for consul-tative purposes, may be an appropriate solution.The overall results were exceedingly positive, with usability andacceptability ratings consistently above 90%. There were some dif-ferences such as the perception of the intrusiveness of the robotbetween the remote and local physicians. This may be due to theinability of the remote physician to perceive the changes that arerequired by the local staffto accommodate therobot. Thetrauma bay is often a limited space shared by multiple personnel and equipment.For example, the robot may interfere with portable imaging equip-ment or with the ability of team members to move freely.Other useful findings documented by the technical support teamincluded issues with the robot’s inability to deal with debris (i.e.,rubber gloves on floor) and difficulty maneuvering in small or crowded spaces. A selective microphone might prove beneficial toavert transmission of peripheral conversations and ambient noise. Additionally, the angle of visibility was sometimes limited whenattempting to view a patient’s thoracoabdominal area. Our researchsuggests that the addition of a camera on a boom or the constructionof a taller robot may help to correct this visibility limitation in thefuture. Also of concern was the ability to effectively clean and dis-infect the robot after it was exposed to biohazardous materials. Werecommend further research into developing new and alternative
Table 1. Comparison of Percentages of Local and RemotePhysicians Who ‘‘Strongly Agree/Agree’’ with PositiveCommunication Statements Related to Their Experiencewith the Remote Presence-7 Robot and Teleconsultation
‘‘STRONGLY AGREE/AGREE’’LOCAL PHYSICIANREMOTEPHYSICIAN
I was able to effectively communicatewith the remote physician/local staff.90% 97% (
+
7%)I feel that the remote physician/localstaff was able to understand myquestions and comments.92% 96% (
+
4%)I was comfortable communicating withthe remote physician/local staff.79% 98% (
+
19%)I was able to hear the remote clinician’s/local staff’s communications clearly.81% 88% (
+
7%)
Table 2. Comparison of Percentage of Local and RemotePhysicians Who ‘‘Strongly Agree/Agree’’ with PositiveGeneral Statements Related to Their Experience withthe Remote Presence-7 Robot and Teleconsultation
‘‘STRONGLY AGREE/AGREE’’LOCAL PHYSICIANREMOTEPHYSICIAN
I felt comfortable using the robot in theclinical environment.87% 93% (
+
6%)I felt comfortable communicating with aremote physician/local staff from a remotelocation.92% 100% (
+
8%)I feel that having access to a remotephysician at all times would be beneficial.92% 99% (
+
7%)
Fig. 2.
Comparison of perceptions of overall experience with theRemote Presence-7 robot.
SCHULMAN ET AL.
250 TELEMEDICINE and e-HEALTH
APRIL 2013

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