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Impact of Telemedicine on Extended Focused Assessment With Sonography for Trauma Performance and Workload by Critical Care Transport Personnel

  • Margaret Siu
    Correspondence
    Address for correspondence: Margaret Siu, MD, UMASS Chan Medical School, Baystate Medical Center, Department of Surgery, 759 Chestnut Street, Springfield, MA 01199.
    Affiliations
    Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
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  • Jeffrey Dan
    Affiliations
    Department of Emergency Medicine, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
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  • Jason Cohen
    Affiliations
    Boston MedFlight, Bedford, MA

    Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA
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  • Yamuna Carey
    Affiliations
    Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA

    Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
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  • Reginald Alouidor
    Affiliations
    Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA

    Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
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  • Kristina Kramer
    Affiliations
    Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA

    Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA
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  • Tovy Haber Kamine
    Affiliations
    Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA

    Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of Massachusetts Chan Medical School, Baystate Medical Center, Worcester, MA

    Department of Healthcare Policy and Population Science, University of Massachusetts Chan Medical School, Worcester, MA
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Published:January 16, 2023DOI:https://doi.org/10.1016/j.amj.2022.12.008

      Abstract

      Introduction

      There are currently no reports on whether telementoring for extended focused assessment with sonography for trauma (eFAST) improves critical care transport providers’ performance in prehospital settings. Our objective was to determine the impact of teleguidance on eFAST performance and quantify workload experience.

      Methods

      Eight trauma injury modules were selected on simulated patients. Critical care transport (CCT) providers were tasked to complete one independent and one emergency physician–telementored eFAST. The time to completion and the percent of correct findings were obtained. Participants completed the NASA Task Load Index after each iteration to assess workload.

      Results

      Eight independent and 8 telementored eFASTs were completed. The mean times to complete the independent and telementored eFAST were 5 minutes 16 seconds (95% confidence interval [CI], 3 minutes 32 seconds, 6 minutes 59 seconds) and 8 minutes 27 seconds (95% CI, 5 minutes 14 seconds, 11 minutes 39 seconds), respectively (P = .06). The percentage of correctly identified injuries for the independent versus the teleguided eFAST was 65% versus 92.5% (P = .01). The CCT providers experienced higher mental (P = .004), temporal (P = .01), and effort (P = .004) demands; greater frustration (P = .001); and subjective lower performance (P = .003) during independent trials. The emergency physician experienced higher mental (P = .001), temporal (P = .02), effort (P = .005), and frustration (P = .001) demands than the CCT members.

      Conclusion

      The teleguided eFAST yielded higher accuracy than the independent eFAST. The CCT providers relied on teleguidance of the remote physician when performing the eFAST. Teleguidance may improve the accuracy of ultrasounds performed by prehospital personnel in real-life scenarios.
      Over the last 2 decades, the clinical use of ultrasound imaging has grown exponentially, and its use in the trauma bay is no exception. The extended focused assessment with sonography for trauma (eFAST) has become a mainstay in the evaluation of trauma patients.
      • Montoya J
      • Stawicki SP
      • Evans DC
      • et al.
      From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment.
      As plain films give way to ultrasound, eFAST is now used as part of the trauma secondary examination in assessing the pericardium, pleura, abdomen, and pelvis.
      • Nandipati KC
      • Allamaneni S
      • Kakarla R
      • et al.
      Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: Experience at a community based level I trauma center.
      ,
      • Hamada SR
      • Delhaye N
      • Kerever S
      • Harrois A
      • Duranteau J.
      Integrating eFAST in the initial management of stable trauma patients: the end of plain film radiography.
      eFAST examinations have also extended outside the confines of the hospital and have been performed successfully by paramedics and other prehospital emergency medical service personnel.
      • Boniface KS
      • Shokoohi H
      • Smith ER
      • Scantlebury K.
      Tele-ultrasound and paramedics: real-time remote physician guidance of the focused assessment with sonography for trauma examination.
      ,
      • Dudek M
      • Dabrowski M
      • Smereka J
      • Drozd A
      • Szarpak L.
      Performance and skill retention of extended focused assessment with sonography for trauma for the paramedics.
      With its minimal radiation risks, relative efficiency in image production, and minimal equipment requirements, the future of rapid assessment of critically ill trauma patients rests heavily on the eFAST.
      • Zieleskiewicz L
      • Fresco R
      • Duclos G
      • et al.
      Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: impact on the management of 756 patients.
      Parallel to the rise of ultrasound has been the evolution of telemedicine. Telemedicine has been used in multiple settings to guide ultrasound, including on the ground, in remote locations, and on the international space station.
      • Cermack M.
      Monitoring and telemedicine support in remote environments and in human space flight.
      • Mohr NM
      • Vakkalanka JP
      • Harland KK
      • et al.
      Telemedicine use decreases rural emergency department length of stay for transferred North Dakota trauma patients.
      • Nicogossian AE
      • Pober DF
      • Roy SA.
      Evolution of telemedicine in the space program and earth applications.
      Exploration in telemedicine has demonstrated that teleguidance for ultrasound, in particular, eFAST, is technically possible. However, there are currently no reports on whether telementoring for eFAST improves critical care transport providers’ capabilities in performing the examination in prehospital or out-of-hospital settings. We are also lacking assessments of mental demands experienced while performing teleguided eFAST. Our objective for this investigation was to discern the impact of teleguidance when provided by a board-certified, ultrasound fellowship–trained emergency physician (EP) to critical care transport (CCT) providers on eFAST performance. In addition, we sought to quantify subjective workload experienced during independent and teleguided eFAST.

      Methods

      Study Design

      This investigation was approved by the institutional review board and institutional scientific review committee (ID 132564-45). We used simulation to depict trauma patients with different thoracic and abdominal injuries requiring eFAST examinations. CCT members were asked to perform an independent and physician-teleguided eFAST on these simulated trauma patients.

      Selection Criteria

      All 21 members of our institution's CCT team were invited to participate. The majority of CCT members expressed interest; however, because of scheduling and availability, only 8 CCT providers were enrolled. Each participant performed an independent eFAST and a teleguided eFAST for a total of 16 iterations. There were 3 registered nurses, 1 paramedic, 3 certified flight paramedics, and 1 participant who is both a certified flight paramedic and a registered nurse. There were 4 female and 4 male participants. The study was performed approximately 2 weeks after all CCT providers completed and passed the Advanced Trauma Life Support (ATLS) course, which includes basic instruction in eFAST performance and interpretation. None of the participants received training in ultrasound or had prior experience with telemedicine. The telementor physician was a board-certified emergency medicine physician with fellowship training in emergency ultrasonography but had no prior experience with telemedicine.

      Simulation

      The simulation was completed using the institution's simulation center and Goldberg Surgical Skills Laboratory (Springfield, MA). Simbionix Mentor Learn (Simbionix, Airport City, Israel) ultrasound eFAST modules were used to simulate critically ill trauma patients.
      • Østergaard ML
      • Konge L
      • Kahr N
      • Albrecht-Beste E
      • Nielsen MB
      • Nielsen KR.
      Four virtual-reality simulators for diagnostic abdominal ultrasound training in radiology.
      The simulation process entailed a Simbionix mannequin; a set of ultrasound probes including phased-array, linear, and curvilinear variations; and a monitor with built-in software that projects live ultrasound imaging correlating to specific modules and dependent on the performer's probe aim. The mannequin was an anatomically correct, life-size structure but did not have actual intrathoracic or intra-abdominal organ structures. It was equiped with software capable of projecting ultrasound images onto the monitor depending on where the probe was positioned for each specific trauma scenario. Each module simulated a specific trauma scenario and its respective pathologies (ie, pericardial effusion, hemothorax, lack of lung sliding, and/or intra-abdominal fluid).
      Each CCT provider was randomly assigned to a specific trauma scenario using a random number generator and asked to complete an independent (without teleguidance) eFAST on the mannequin and then to complete an assessment on their clinical findings. After the independent eFAST, they were randomly assigned to another specific trauma scenario. CCT providers were tasked to complete the second trauma scenario with its own set of pathologies under the teleguidance of an EP and then again to complete an assessment of clinical findings.
      Teleguidance was completed using Zoom (Zoom Video Communications, San Diego, CA) videoconferencing and screen sharing capabilities of the monitor to allow the EP to interact with the eFAST performer and analyze ultrasound images in real time on the physician's own screen. The EP was situated in a remote location in a separate building from the simulation center. Institutional Wi-Fi and cellular data were used for Zoom connections; there were no issues with bandwidth or lag time, although the actual lag time was not calculated in these iterations. CCT providers and the EP were asked to complete the NASA Task Load Index (TLX), a validated survey for mental and physical workload assessment, after performing the eFAST and teleguidance, respectively.
      • Hoonakker P
      • Carayon P
      • Gurses AP
      • et al.
      Measuring workload of ICU nurses with a questionnaire survey: the NASA task load index (TLX).
      • Stanton N
      • Salmon PM
      • Rafferty LA
      • Walker GH
      • Baber C
      • Jenkins DP.
      Mental Workload Assessment Method. Human Factors Methods: A Practical Guide for Engineering and Design.
      • Hart SG.
      NASA-task load index (NASA-TLX); 20 years later.

      Data Collection

      The study groups were independent eFAST and teleguided eFAST. Eight modules with specific traumatic injury scenarios were abstracted for the study. Each participant was randomly assigned 2 modules, one for independent eFAST and one for teleguided eFAST. During the procedures, the variables collected include the credentials of each participant, the time required to complete eFAST, and the score of the post-eFAST clinical assessment characterizing the percentage of correctly identified pathology on ultrasound. Possible pathologies included fluid in the pericardium, right/left thorax, right upper quadrant, left upper quadrant, and suprapubic regions and the lack of right/left lung sliding. All participants, including the telementor, completed the NASA TLX survey after each eFAST. This survey consists of 6 areas of demand: mental demand, physical demand, temporal demand, performance, effort, and frustration. Participants graded the level of demand on a continuous scale up to 10, with 10 representing the highest demand.
      • Stanton N
      • Salmon PM
      • Rafferty LA
      • Walker GH
      • Baber C
      • Jenkins DP.
      Mental Workload Assessment Method. Human Factors Methods: A Practical Guide for Engineering and Design.
      ,
      • Hart SG.
      NASA-task load index (NASA-TLX); 20 years later.
      For performance, optimal performance is 1, whereas failure is 10.

      Statistical Analysis

      The mean time needed to conduct eFAST and the mean assessment scores were calculated for independent and teleguided eFAST, and 95% confidence intervals (CI) were obtained for each group. The difference between the groups was analyzed using the t-test. The sensitivity, specificity, positive predicative value (PPV), and negative predicative value (NPV) of eFAST in identifying specific injuries were calculated. The average demand scores from the NASA TLX for each of the 6 areas were calculated for independent and teleguided trials for CCT providers and after teleguidance trials for the EP. The demand scores for each of the areas were compared using t-tests.

      Results

      Of the 8 CCT providers enrolled, each participant performed an independent eFAST and a teleguided eFAST for a total of 16 iterations. The average times to complete the independent and telehealth-guided eFAST were 5 minutes 16 seconds (95% CI, 3 minutes 32 seconds, 6 minutes 59 seconds) and 8 minutes 27 seconds (95% CI, 5 minutes 14 seconds, 11 minutes 39 seconds), respectively (P = .06). The average percentages of correctly identified injuries on eFAST were 65.0% (95% CI, 45.0%, 85.0%) for independent eFAST and 92.5% (95% CI, 85.1%, 99.9%) for teleguided eFAST (P = .01).
      The sensitivity and specificity of different pathologies detected by the sonogram were also determined. Table 1 summarizes the average sensitivity and specificity for the independent and teleguided eFAST. Sensitivity was greater in the teleguided group for the detection of pericardial, thoracic, and abdominal fluid and a pneumothorax. Specificity was greater in the teleguided group for the detection of thoracic and abdominal fluid and a pneumothorax but similar between groups for the detection of pericardial fluid. PPV and NPV are presented in Table 2, with the teleguided group yielding higher PPV and NPV for all views.
      Table 1The Sensitivity and Specificity of Extended Focused Assessment With Sonography for Trauma (eFAST) Performed by Critical Care Transport Members in the Detection of Specific Injuries
      Independent Sensitivity (95% CI)Teleguided Sensitivity (95% CI)Published SensitivityIndependent Specificity (95% CI)Teleguided Specificity (95% CI)Published Specificity
      Pericardial fluid0.50 (0.10, 0.91)1.0 (0.21, 1.0)0.91
      16.
      1.0 (0.61, 1.0)1.0 (0.65, 1.0)0.94
      16.
      Thoracic fluid0.33 (0.060, 0.79)1.0 (0.34, 1.0)0.43
      18.
      0.77 (0.50, 0.92)0.93 (0.69, 0.99)0.98
      18.
      Pneumothorax0.67 (0.21, 0.94)1.0 (0.34, 1.0)0.59-0.69
      16.
      ,
      17.
      0.69 (0.42, 0.87)0.92 (0.67, 0.99)0.99
      16.
      ,
      17.
      Abdominal fluid0.83 (0.55, 0.95)0.93 (0.69, 0.99)0.74
      16.
      0.50 (0.25, 0.75)0.82 (0.52, 0.95)0.98
      16.
      CI = confidence interval.
      a 16.
      b 18.
      c 17.
      Table 2The Positive Predictive Values and Negative Predictive Values of Extended Focused Assessment With Sonography for Trauma (eFAST) Performed by Critical Care Transport Members in the Detection of Specific Injuries
      Independent Positive Predictive Value (95% CI)Teleguided Positive Predictive Value (95% CI)Independent Negative Predictive Value (95% CI)Teleguided Negative Predictive Value (95% CI)
      Pericardial fluid1.0 (0.21, 1.0)1.0 (0.21, 1.0)0.86 (0.49, 0.97)1.0 (0.65, 1.0)
      Thoracic fluid0.25 (0.050, 0.70)0.67 (0.21, 0.94)0.83 (0.55, 0.95)1.0 (0.77, 1.0)
      Pneumothorax0.33 (0.10, 0.70)0.67 (0.21, 0.94)0.90 (0.60, 0.98)1.0 (0.76, 1.0)
      Abdominal fluid0.63 (0.39, 0.82)0.86 (0.60, 0.96)0.75 (0.41, 0.93)0.90 (0.60, 0.98)
      CI = confidence interval.
      A total of 24 NASA TLX surveys were completed to describe participants’ workload demands during eFAST examinations. Results of the NASA TLX data are displayed in Figure 1. Among the CCT providers, demand in the areas of mental (P = .004), temporal (P = .010), performance (P = .003), effort (P = .004), and frustration (P = .001) all significantly decreased transitioning from the independent to the teleguided eFAST. Physical demand did not significantly change (P = .29). Comparing the experiences of the CCT providers conducting independent eFAST against the EP, experience in performance ranked greater in the EP than the CCT members and was the only significant change in demands (P = .004) between the EP and the CCT providers. Comparing the experiences of the CCT providers conducting the teleguided eFAST against the EP, the EP reported higher demands in mental (P = .001), temporal (P = .019), performance (P = .751), effort (P = .005), and frustration (P = .001) areas. Subjective physical demand was lower in the EP compared with the CCT members in the teleguided eFAST (P = .112), although it was not statistically significant.
      Figure 1
      Figure 1The CCT members performing eFAST and the ultrasound-trained EP providing teleguidance on eFAST describing their workload demand in 6 different areas using the NASA TLX. The average scores are out of 10; they are shown here with the 95% CI. For performance, a score of 1 represents optimal performance, and a score of 10 represents minimal performance.

      Discussion

      As the use of sonography has become indispensable in evaluating critically ill trauma patients and burgeoning technology enables the growth of telemedicine, we confirmed the technical possibility of incorporating telemedicine into CCT providers performing eFAST.
      • Williams SR
      • Perera P
      • Gharahbaghian L.
      The FAST and E-FAST in 2013: trauma ultrasonography.
      However, our objective was to not only show that teleguided eFAST is possible but also to demonstrate the impact of telemedicine on eFAST performance.
      Our primary outcomes included comparing the accuracy and time needed to complete eFAST between examinations performed with and without teleguidance. The average percentage of correctly identified injuries is significantly higher in the teleguided trials compared with the independent trials (92.5% vs. 65%, respectively). A 2012 study focusing on the effectiveness of eFAST training curricula demonstrated an average of 75% of injuries correctly identified by CCT members after a 2-month training period using didactic courses, hands-on training sessions, and proctored scanning sessions.
      • Press GM
      • Miller SK
      • Hassan IA
      • et al.
      Evaluation of a training curriculum for prehospital trauma ultrasound.
      Our CCT members preformed similarly (within 95% CIs) to this previously published data after just a single ATLS course, and telemedicine permitted CCT members to perform ultrasound with a higher degree of accuracy than those who underwent 2 months of training. The 92.5% accuracy found with teleguidance is an encouraging finding on the benefits of integrating telehealth into prehospital eFAST programs. Although teleguided eFAST required more time, the time difference between groups was not significant and is consistent with the published literature.
      • Boniface KS
      • Shokoohi H
      • Smith ER
      • Scantlebury K.
      Tele-ultrasound and paramedics: real-time remote physician guidance of the focused assessment with sonography for trauma examination.
      We also obtained the sensitivity and specificity for the 2 types of examinations. Table 1 summarizes our sensitivity and specificity and compares them with published values. The sensitivity and specificity with 95% CIs were higher in the teleguided group for the detection of pericardial, thoracic, and abdominal fluid and a pneumothorax compared with the independent group. Sensitivities varied between different views, and independent eFAST sensitivities were within range among the literature values. Our teleguided specificity values were similar to the literature values in all views.
      • Netherton S
      • Milenkovic V
      • Taylor M
      • Davis PJ.
      Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis.
      • Kirkpatrick AW
      • Sirois M
      • Laupland KB
      • et al.
      Hand-Held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST).
      • Akoglu H
      • Celik OF
      • Celik A
      • Ergelen R
      • Onur O
      • Denizbasi A.
      Diagnostic accuracy of the extended focused abdominal sonography for trauma (E-FAST) performed by emergency physicians compared to CT.
      In addition to the specificity results, the higher PPV and NPV of teleguided eFAST further reinforce the benefits of incorporating teleguidance in prehospital eFAST.
      To understand how the introduction of teleguidance to eFAST improved accuracy rates, we investigated the mental and physical demands of providers using the NASA TLX. Previous reports presented accuracy rates of eFAST examinations completed in the trauma bay similar to our teleguidance eFAST abilities.
      • Netherton S
      • Milenkovic V
      • Taylor M
      • Davis PJ.
      Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis.
      ,
      • Khosravian K
      • Boniface K
      • Dearing E
      • et al.
      eFAST exam errors at a level 1 trauma center: a retrospective cohort study.
      This information suggests that the accuracy of our teleguided examinations is a result of eFAST being mentally performed by the EP while using the CCT provider as a physical body manipulating the probe during teleguided eFAST. Using the NASA TLX, we showed the mental, temporal, effort, and frustration demands of the task shifting from the CCT provider to the EP. Specifically, while performing the teleguided eFAST, the EP had similar scores in demand areas experienced by the CCT member when performing the independent eFAST. Moreover, during the teleguided eFAST, the CCT members had significantly lower scores in the same areas. Unsurprisingly, there was no difference in the physical demand of the CCT members among both examinations. The significant improvement in performance is internally consistent with the accuracy data and likely reflects the expertise of the EP in interpreting eFAST images.
      The mental and physical demands experienced by the CCT and the EP provide insight on how teleguided eFAST may be useful in implementing point-of-care ultrasound during the prehospital workup of trauma patients. In our study, CCT members underwent ATLS ultrasound training before conducting the eFAST as the only prestudy experience. It is understandable that there may be hesitance and anxiety when performing the independent eFAST and needing to identify correct pathologies. Having board-certified, ultrasound-trained physician guidance, even if only remotely, would tremendously augment the level of comfort. This was demonstrated in the NASA TLX data.
      Our study is limited by several factors. We only involved a single EP, which leads to a lack of generalizability, especially when this particular physician has specific training in ultrasound. We are further limited by the prestudy CCT team training. Although they all received the same training (ie, ATLS), this training is likely not sufficient to perform independent eFAST as previous studies have shown.
      • Press GM
      • Miller SK
      • Hassan IA
      • et al.
      Evaluation of a training curriculum for prehospital trauma ultrasound.
      Although we used a simulation model with specially designed trauma modules, our eFAST trials did not include the distractions and surrounding environment that CCT providers typically experience, thus limiting the stress level that is usually involved.
      Lastly, our study heavily depended on the technology allowing telemedicine and, subsequently, the teleguided eFAST to be possible. We used the institution's Wi-Fi and cellular data to enable teleconferencing and screen sharing. In our experience, there was minimal lag time because both the eFAST performer and the telementor were situated in a physical location where the Wi-Fi connection and cellular data network were stable. However, as previous literature has shown, bandwidth limitations may be of issues to telemedicine in certain situations.
      • Barba P
      • Stramiello J
      • Funk EK
      • Richter F
      • Yip MC
      • Orosco RK.
      Remote telesurgery in humans: a systematic review.
      ,
      • Kamine TH
      • Smith BW
      • Fernandez GL.
      Impact of time delay on simulated operative video telementoring: a pilot study.
      For instance, in rural areas where connections are limited, real-time image sharing would be hindered by signal latency. Incorporating presumed lag times of image sharing and communications may have yielded different results. Additional work and resources must be dedicated to technology ensuring stable and continuous connections between the CCT members and the telementor.
      With the information we learned from this investigation, our goal is to pilot teleguided eFAST to CCT members in the field caring for real-life, critically ill trauma patients. This study enables us to confidently declare the superiority of teleguided prehospital eFAST over CCT members independently performing eFAST. Moving forward, we plan to transfer the technology we used here, including direct communication and video sharing abilities, to provide the best possible imaging and assessment of patients. By optimizing the details of telemedicine and prehospital assessments, we hope to usher in a new standard for prehospital care of trauma patients.

      Conclusion

      Trauma care is increasingly recommending prehospital assessments, including eFAST, before trauma bay arrival. The use of telemedicine involving an ultrasound-trained provider guiding prehospital personnel in eFAST yields significantly improved accuracy. In this study, CCT providers relied heavily on the teleguidance of a remote physician to perform eFAST. Teleguidance may improve the accuracy of ultrasound performed by prehospital providers in real-life situations.

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