Paediatric cardiac telemedicine – transmitting echocardiography images in Wales

Abstract

We started a telemedicine service for paediatric cardiology work in 2006, enabling transmission of echocardiography images via videoconferencing equipment to the specialist paediatric cardiac department at Cardiff for review and/or diagnosis. The system has been used regularly for a range of paediatric cardiology cases. Despite increasing the transmission bandwidth to 1 Mbit/s the transmission of live echocardiography was still considered to be suboptimum. Nonetheless, the implementation of a simple telemedicine service has demonstrated the feasibility of transmitting echocardiography images via videoconferencing equipment for diagnosis and second opinions.

Introduction

Echocardiography examinations undertaken at the paediatric department at Singleton Hospital in Swansea sometimes require second opinions or diagnosis on complex or rare conditions. This resulted in the cardiologist having to travel to Swansea from the paediatric cardiac centre in Cardiff (68 km), often at night when the consultant was on call. Alternatively, video recordings were posted or sent by courier to Cardiff for review. This was felt to be unsatisfactory because it caused delay in diagnosis and treatment.

There is considerable experience with the use of telemedicine in paediatric cardiology.^1–3 We therefore decided to introduce a telemedicine service in Wales.

Methods

A video-player was obtained and existing videoconferencing facilities in the Cancer Centre at the hospital were used to make test videoconference calls. The tests were made to the Cardiac Department at Cardiff, using the Welsh Health Video Network (digital IP Network at 384 kbit/s) and videos were transmitted. The quality of the images was judged by both sites to be of diagnostic standard, and agreement was reached that review and diagnosis of echocardiography videos via videoconferencing was feasible.

The telemedicine service commenced in July 2006. By October 2006, several successful transmissions had been undertaken which had resulted in a faster diagnosis and treatment plan for patients and fewer journeys for the consultant cardiologist. However, the set-up process for transmission was cumbersome as it involved transporting the video-player on a trolley some distance across the hospital site. It also relied on the availability of the videoconferencing equipment (which was often being used by others) which contributed to difficulties in undertaking ad hoc or out of hours transmissions. It was agreed therefore to procure dedicated videoconferencing equipment for the paediatric department.

New videoconferencing equipment was installed in June 2007. The transmission bandwidth was increased from 384 kbit/s to 768 kbit/s. A series of test calls was made, with live images compared to video image transmission. It was agreed that the video images were of better diagnostic quality, that transmission of live echocardiography was feasible for review and discussion, and that video recordings were feasible for diagnosis. In September 2007 the image quality was further improved by an increase in transmission bandwidth to 1 Mbit/s. However, transmission of live echocardiography was still considered to be suboptimum and work is currently being undertaken to upgrade the equipment to higher definition.

Discussion

The system has been used regularly for a range of paediatric cardiology cases (Figure 1). Examples of more complex uses are summarised in Table 1. The implementation of a simple telemedicine service has demonstrated the feasibility of transmitting echocardiography images via videoconferencing equipment for diagnosis and second opinions. Our experience suggests that telemedicine has benefits for both patients and staff, and helps to provide support from a specialist centre some distance away. The benefits include:

Quicker diagnosis and treatment planning;

More efficient use of specialist staff;

Immediate feedback of specialist support to the clinical physiology staff;

A less frequent need for the consultant cardiologist's team's travel to the Singleton Hospital (especially when on call);

Reduced travel expenses;

Guidance/supervision of newly qualified staff in echocardiography;

Opportunity for increased staff participation in educational meetings, resulting in more people with broader range of experience;

Development of new clinical and professional working relationships.

Figure 1

Clinical physiologist undertaking echocardiography and transmitting the scan via videoconference

Table 1

Examples of more complex telemedicine cases

Scenario	Outcome of the teleconsultation
Baby born by caesarean section noted to have a heart murmur. Possibility of truncus arteriosus with interrupted aortic arch on echocardiography.	Diagnosis confirmed. Arrangements made with the Bristol retrieval team to collect the patient for surgery. On-call consultant not required to leave site, so little disruption to work schedule. No delay while waiting for the arrival of the consultant. Repeat echocardiography not required.
Suspected aortopulmonary window.	Diagnosis confirmed. Direct patient transfer to Bristol agreed. Patient reassured. No delay while waiting for the arrival of the Cardiff consultant who also provided medication advice. Multidisciplinary group of clinicians at Cardiff – educational opportunity as fairly rare condition.
Suspected Kawasaki disease. Opinion required on prominent coronary artery. Possible aneurysm.	Kawasaki disease ruled out. The diagnosis of prominent coronary artery was confirmed with no aneurysm. Reassurance was given to the parents. No delay while waiting for the arrival of the Cardiff consultant who provided medication advice. Multidisciplinary group of clinicians at Cardiff – educational opportunity as fairly rare condition.
Pre-term baby born with large patent ductus arteriosus. Cardiologist opinion required to instigate surgery.	Diagnosis confirmed. Arrangements made for transfer of patient to Bristol. Parents reassured. Treatment delay avoided.
Abnormality queried during a routine ante-natal scan.	The Cardiff consultant guided the sonographer during rescan via telemedicine. Diagnosis made of fetal supraventricular tachycardia. Treatment commenced immediately, avoiding potential fetal complications. Specialist supervision was available during the scan. Educational opportunity for sonographer.
Four consultations – patient/parent, Great Ormond Street consultant and team.	Four journeys to London avoided. Parents were delighted.

The work also provided a more efficient method of delivering staff training. The introduction of teaching sessions using videoconferencing has also proved useful. Linking colleagues in a videoconference enables the sharing of information and presentations, and demonstrates the potential in undergraduate and postgraduate education. This could be developed to include supervision and training of echocardiography technicians. Finally, the telemedicine service has been much appreciated by the patients.

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