Abstract
Introduction:
Acute care telemedicine is a critical resource for rural and community Emergency Medicine (EM) providers. To address potential barriers and promote use of these services throughout our health system Emergency Departments (EDs), we embed telemedicine consultations within in situ simulations.
Materials and Methods:
Care teams in health system EDs participated in multidisciplinary in situ simulations that focused on Difficult Airway management or Obstetric Emergencies. Physicians in EM and Neonatology at the referral center were available for assistance via telemedicine consultation. Participants were then surveyed regarding their experience with the telemedicine consultation during the simulations.
Results:
Participants reported increased likelihood to use telemedicine as well as increased understanding of the technology, awareness of available consultation services, and comfort interacting with the consultant.
Conclusions:
Embedding telemedicine consultations into in situ EM simulations is an effective approach to address implementation barriers and may promote increased use of telemedicine services among rural and community EM providers.
Introduction
Telemedicine is a critical resource for rural, resource-limited Emergency Departments (EDs). It has been shown to alter diagnosis and treatment, decrease door-to-provider time, facilitate specialty consultation, improve timely administration of therapy, and reduce unnecessary patient transfers. 1 –5 Consultations are initiated by the rural or community Emergency Medicine (EM) provider on an as-needed basis, so buy-in from the remote clinician is essential. 1,6 Barriers known to limit implementation and use of telemedicine include lack of training on use of the technology, lack of awareness of service availability, and lack of perceived need by the remote providers, 6 –10 as well as uncertainty regarding appropriate indications for consultation. 7,8
At our institution, the Emergency Medicine Community Simulation Program (EMCSP) uses simulation to promote practice standardization, provide ongoing education and training, and facilitate quality and process improvement across our health system EDs. Our health system includes 20 EDs serving 40 counties in the upper Midwest (including 24 rural 11 counties). There are 11 federally designated critical access hospitals (CAH), several moderately sized community EDs, and one academic referral center. Consequently, available resources vary significantly across sites. Recognizing telemedicine as a resource globally available in our health system EDs, we embed telemedicine consultations into in situ (occurring in the clinical setting rather than at a simulation center) EM simulations to promote integration of telemedicine into local EM practices.
Although telesimulation has been previously described, 12 –16 this is distinct from our use of on-site training to practice using telemedicine services to care for simulated patients. And while in situ simulation has been used to evaluate telemedicine in the ED, 17 –20 most studies focused on feasibility 18 –20 or team performance. 19,20 Using in situ simulation to facilitate adoption of telemedicine into existing workflows has only recently been described. 17
We sought to determine whether embedding telemedicine consultation into in situ EM simulations would improve knowledge and comfort with use of the technology, increase awareness of service availability, and increase likelihood of use of telemedicine services. Herein, we provide a descriptive analysis of our experience utilizing in situ simulation to promote use of telemedicine resources in our system-wide EM practice.
Materials and Methods
DESIGN
This multicenter, prospective simulation-based cohort study measured team member perceptions and lessons learned using real-time telemedicine consultation to aid in the care of simulated patients in community EDs. The study was reviewed and considered exempt by our institutional review board. Participants signed a consent form agreeing to participate and be recorded.
SETTING AND PARTICIPANTS
EM care teams in community EDs volunteered to participate in multidisciplinary in situ simulation sessions through the EMCSPs ongoing training and education efforts. Sessions were announced, and participants were protected from clinical responsibilities during the sessions. Teams from one moderately sized community ED and six community critical access EDs participated in our Difficult Airway course, Obstetric Emergencies course, or both over a 2-year period from October 2017 to November 2019. All scenarios were run in an ED patient room when possible; however, two Difficult Airway sessions and one Obstetric Emergencies session were held in vacant inpatient rooms secondary to high ED patient census. Skills stations and debriefs were performed in conference rooms or adjacent vacant inpatient rooms.
PROTOCOL
Each group participated in a 4-h simulation session. The Difficult Airway curriculum consists of three simulation cases: an adult with an acute chronic obstructive pulmonary disease exacerbation requiring endotracheal intubation, a toddler with smoke inhalation injury requiring endotracheal intubation, and an adult with blunt neck trauma requiring cricothyrotomy. It also included skills stations for procedural task training: adult and pediatric endotracheal intubation, the use of airway adjuncts, supraglottic devices, and cricothyrotomy. The Obstetric Emergencies curriculum consists of four simulation cases: an imminent delivery complicated by postpartum hemorrhage, an imminent delivery complicated by shoulder dystocia requiring neonatal resuscitation, eclampsia, and a traumatic arrest with perimortem cesarean section.
For each scenario, participants were organized into teams reflecting the composition of care teams in the ED at that site. Typically, this includes one or two providers (physicians or advanced practice providers [APPs]) and two to three nurses. Participants in larger groups were broken into appropriate subgroups and alternated providing direct bedside care of the simulated patient for each scenario while the others observed. Observers viewed the case via livestream (SimCapture; B-Line Medical, Washington, DC) and actively participated during the debrief, which included all participants, faculty, and other observers (such as local leadership from nursing, ED, Obstetrics [OB], or patient safety).
During the simulations, resources were limited to what would be available at that site during a clinical encounter in the ED. Physicians in EM and Neonatology at the academic referral center could be contacted for real-time telemedicine consultation during these simulated cases (TeleEM and TeleNeonatology, respectively) (InTouch Technologies, Inc., Santa Barbara, CA). The flow and progression of the cases were facilitated by an embedded instructor who prompted providers to consult telemedicine or assisted with establishing the connection if needed.
High-fidelity patient simulators used included Victoria S2200 and Pediatric HAL S3004 (Gaumard, Miami, FL), and SimMan 3G and Neonatal Resuscitation Baby (Laerdal, Wappingers Falls, NY). In some of the imminent delivery cases, a volunteer patient actress was augmented with Mama Natalie (Laerdal). Either the Victoria surgical abdomen or SimMan 3G with a modified “Casserole Perimortem Caesarean Section Model” 21 was used to perform the perimortem cesarean section procedure.
DATA COLLECTION
Participants were asked to complete an online survey (
The survey gathered demographic information via multiple choice questions. Telemedicine use was assessed with the following two questions: “Had you ever used telemedicine prior to the simulation session?” and “Have you used telemedicine since participating in the simulation session?” Lessons learned were assessed with the question: “What did you gain from using telemedicine during the simulation session?” For each of these questions, multiple responses could be selected from a list or free-texted in an “other” category.
Likelihood of telemedicine use was assessed with the following two questions: “How likely were you to use/consider using TeleEmergency Medicine or TeleNeonatology prior to participating in the simulation session?” and “How likely are you to use/consider using TeleEmergency Medicine or TeleNeonatology since participating in the simulation session?” These responses were rated on a scale from “Not Likely” to “Very Likely,” which generated a number from 0 to 100.
DATA ANALYSIS
Survey responses regarding likelihood of telemedicine use are summarized with mean scores, both overall and divided by participant role. Likelihood of simulation use after simulation data is compared with likelihood of simulation use before simulation data using the paired-sample Wilcoxon signed-rank tests. All tests are two-sided, and p-values <0.05 are considered significant. All analyses were conducted using R version 3.6.2. 22
Results
In total, 10 simulation sessions were held and 123 individuals participated in 1 or more session: 16 physicians, 27 APPs, 67 nurses, and 13 others (Respiratory therapist, Emergency Medical technician or Paramedic, ED technician, etc.). One hundred eleven participants (90.2%) were reachable via email and asked to complete the survey. Of those, 57 participants (51.4%) completed the survey. Demographic information of the survey respondents is listed in Table 1. Ninety-three percent had used telemedicine before participating in the simulation session. Of those, the most frequently utilized service was TeleStroke (Neurology).
Participant Demographic Information
N = number of survey respondents of that participant type (percentage of total survey respondents).
N = number of survey respondents of that participant type (percentage of survey respondents of that participant type).
Clinical time in ED = percentage of clinical time spent providing direct patient care to patients in the ED.
APP, advanced practice provider; ED, Emergency Department.
Participants were asked what they learned from using telemedicine during the simulation scenarios. The responses fit into three themes (Fig. 1): improved understanding of the technology (including how to initiate a consult, use of the device, and/or understanding that all telemedicine services connect via the same device), improved awareness of services available for consultation (including TeleStroke, TeleEM, TeleEM Pharmacist, and TeleNeonatology consultation services), and increased comfort interacting with the consultant during patient care. Most commonly, participants noted that they were more comfortable initiating the consultation (40.4%) and interacting with the consultant while providing patient care (49.1%). Many reported that they were now aware of TeleNeonatology (42.1%) or TeleEM (22.8%) service availability. Some reported that they did not learn anything new about telemedicine consultations (12.3%).
Lessons learned incorporating telemedicine consultation into in situ Emergency Medicine Simulations. Participants were asked what they learned about acute care telemedicine from their experience using telemedicine during the simulation sessions. Participants could choose one or more items from a list or provide their own in an open-ended “Other” category. Data are reported in total for the group (all participants) as well as the providers (advanced practice providers and physicians) and nurses. Data are reported as the percentage of participants who responded to the survey.
All participant groups noted that they would be more likely to use or consider using TeleEM or TeleNeonatology services after participating in the simulations (Overall p < 0.001; Table 2). This difference was significant among nurses and APPs (Nurse: p = 0.004; APPs: p = 0.045).
Participants' Likelihood of Use of TeleEM or TeleNeonatology Services from the Emergency Department
Data reported are averages.
Note: Participants were asked how likely they would be to use/consider using TeleEM or TeleNeonatology services before and after participating in the simulation session. This was rated on a scale that generated a corresponding numeric value ranging from 0 (not likely) to 100 (very likely).
p-Values are computed from the Wilcoxon signed-rank tests.
Denotes statistical significance (p < 0.05).
Discussion
After simulation training, participants noted increased familiarity with the telemedicine technology and workflows and improved awareness of available services for consultation. Nurses most frequently reported improved understanding of the technology, whereas providers most frequently reported better understanding of service availability. This most likely reflects differences in workflows between the two groups. Typically, nurses bring the device to the bedside and interact with it during the consultation, whereas providers determine the need for telemedicine consultation.
Participants in all groups noted that they are more likely to use TeleEM or TeleNeonatology after participating in the simulations; the greatest change was noted in the nursing and APP groups. Interestingly, APPs staffing CAH EDs reported a nearly twofold increased likelihood of use compared with those staffing community EDs (data not shown). This may reflect differences in staffing models between EDs. APPs staffing CAH EDs in our health system are the sole provider on duty, whereas APPs in community EDs have an EM physician working beside them and may be more likely to utilize that physician for assistance rather than the TeleEM service. This trend is consistent with prior studies noting that EDs that utilize telemedicine are more likely to be rural, have fewer beds or lower median visit volumes, and fewer full-time attending physicians than EDs that do not utilize telemedicine. 10,23
The least change, and the lowest likelihood of use overall, was noted in the physician group. EM physicians in our health system are Board Eligible (BE) or Board Certified (BC) in EM and are presumably more comfortable caring for critical patients without telemedicine support. This seems particularly true regarding TeleEM consultations. One physician commented, “I am thankful [telemedicine] is available for less experienced providers.” Another commented, “I am unlikely to use telemedicine for EM, but would like it for Neonatology.”
This may reflect a unique obstacle surrounding “same-specialty” consultation. Much of the TeleEM literature describes systems in which the consulting rural EM provider is an APP or primary care provider rather than a BE/BC EM physician. 2,24 Some authors suggest that local providers' fear their competence is being questioned by the telemedicine provider and that this fear is another potential barrier to telemedicine use. 6 Perhaps, this fear of perceived incompetence is exacerbated when consulting within one's specialty versus consulting a subspecialist. There may also be little perceived benefit on the part of the community EM physician in formally consulting another EM physician.
Embedding telemedicine consultation within in situ simulation is a newly described and novel approach to facilitate integration of this technology into established rural and community EM practices. 17 Our findings are consistent with prior similar studies 17,18 and add to this growing body of literature.
LIMITATIONS
Our analysis has several limitations. First, the TeleEM service was new with varied availability between simulation sessions. Because we wished to include all who had participated in simulation with telemedicine to date at the time of our analysis, there is variability in the time between participation in the session and completion of the survey. Therefore, our survey results are subjected to recall bias. Additionally, participants may have had additional experience with telemedicine in the interim that could have influenced their responses, particularly with regard to their likelihood of using telemedicine services.
Conclusions
Embedding telemedicine consultation within in situ EM simulation effectively addresses several barriers to telemedicine use in rural and community EDs. Overall, participants are more likely to use telemedicine services after participating in these in situ simulation sessions. The apparent barrier of “same-specialty” physician consultation (EM to EM) merits further research.
Footnotes
Authors' Contributions
The authors participated in study design, data acquisition and interpretation, article preparation and revision, and are accountable for all aspects of this work.
Acknowledgments
The authors would like to thank the Multidisciplinary Simulation Center for their assistance in organizing and delivering the simulation curriculum to the health system Emergency Medicine care teams, the TeleEM and TeleNeonatology providers for their collaboration and participation, and Aidan F. Mullan for assistance with statistics and data analysis. Additionally, the authors thank the Department of Emergency Medicine for their vision and support of telemedicine and simulation-based training.
Disclosure Statement
No competing financial interests exist.
Funding Information
This work was sponsored by the Department of Emergency Medicine's ongoing education and quality improvement initiatives and by the Mayo Clinic Multidisciplinary Simulation Center, which provided funding and resources to support the Emergency Medicine Community Simulation Program.