Value

Oral Presentation

(V3-03) Utilization and Clinical Outcomes for Trauma Patients Treated with Telemedicine in Rural North Dakota Hospitals

Sunday, April 23
2:25 PM - 2:45 PM
Location: W230 BC

Objectives
Traumatic injury is a leading cause of death in the U.S., and rural populations are at increased risk of injury and death. Telemedicine has been proposed as one strategy to improve the provision of rural trauma care locally, and many rural North Dakota hospitals have subscribed to an emergency department (ED)-based telemedicine service. The objectives of this study are to:
1. Describe use of telemedicine for trauma patients in North Dakota, with a focus on identifying factors associated with telemedicine consultation;
2. Measure the impact of telemedicine consultation on rate and timeliness of inter-hospital transfer among trauma patients; and
3. Analyze the effect of telemedicine consultation on the rate of trauma imaging studies and mortality.

Methods
Cohort study of all adult (age≥18 y) trauma patients treated in North Dakota critical access hospital EDs from 2008-2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations (clustered on rural hospital) were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and clinical outcomes, adjusting for patient, injury, and hospital factors.

Results
Of the 7,500 trauma patients seen in critical access hospitals during the study period, 2,662 were treated in a telemedicine-capable ED. Telemedicine was consulted for 11% (n=291) of trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher injury severity score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness and type of injury, telemedicine use was not associated with an increased use of inter-hospital transfer (aOR 1.22, 95%CI 0.83-1.80, p=0.313). Among transfer patients, telemedicine was associated with decreased initial ED length-of-stay of 31 minutes (95% CI 15-45min, p < .001), but no difference was observed among those not transferred (p=0.386). Adjusting for injuries and severity of illness, telemedicine use was not associated with increased X-ray use (aOR 1.07, 95%CI 0.79-1.47, p=0.659) or CT scan use (aOR 0.95, 95%CI 0.70-1.30, p=0.749) at the index ED, there was no difference in survival (aOR 0.88, 95%CI 0.56-1.40, p=0.592).

Conclusion
ED-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially for those with penetrating trauma, burns, and abnormal vital signs. Telemedicine consultation was not independently associated with increased probability of transfer, but among transferred patients telemedicine was associated with shorter ED length-of-stay before transfer. Telemedicine was not associated with increased radiography usage at the index ED or mortality. Future work should evaluate how telemedicine can best be implemented to target patients likely to benefit from telemedicine consultation.

Nicholas M. Mohr

Associate Professor
Rural Telehealth Research Center, University of Iowa Carver College of Medicine

Dr. Nicholas Mohr is an Associate Professor of Emergency Medicine and Anesthesia Critical Care at the University of Iowa, and is an investigator in the Rural Telehealth Research Center. Dr. Mohr graduated from the University of Iowa Carver College of Medicine and completed his Emergency Medicine residency at Indiana University followed by his fellowship in Critical Care at Washington University. His research interests include early sepsis care, rural emergency services, and telemedicine use in rural emergency departments, authoring over 35 peer-reviewed manuscripts and nearly 20 book chapters.

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Priyanka Vakkalanka

Graduate Research Assistant
Department of Emergency Medicine, University of Iowa Carver College of Medicine

I am a doctoral student in the Department of Epidemiology at the University of Iowa College of Public Health, and a graduate research assistant in the Department of Emergency Medicine at the University of Iowa Carver College of Medicine. I completed my undergraduate degrees in chemistry and sociology at the University of Virginia, and a masters of science in epidemiology at the Johns Hopkins Bloomberg School of Public Health. I previously worked as an epidemiologist with the Navy and Marine Corps Public Health Center, followed by four years in the Department of Emergency Medicine at the University of Virginia Health System. My primary research interests span across the fields of psychiatric epidemiology, pharmacoepidemiology, and clinical/health services outcomes.

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Amanda Bell

eCARE Quality & Innovation Officer
Avera eCARE

Mandy Bell is the eCARE Quality & Innovation Officer at Avera Health in Sioux Falls, SD and works with each of the Avera’s eCARE telemedicine teams to demonstrate performance outcomes. Mandy specializes in new service line launches and also leads public policy efforts related to Avera’s telehealth programs. She serves as Avera's principal investigator on eEmergency related research programs and assisted with several peer-reviewed manuscripts. Mandy has a Masters in Healthcare Administration from the University of Minnesota.

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Marcia M. Ward

Professor
Department of Health Management and Policy, University of Iowa College of Public Health

Dr. Ward is a Professor in the Department of Health Management and Policy and Director of the Center for Health Policy and Research in the Department of Health Management and Policy, College of Public Health, University of Iowa. Her 35 years of research experience focus on health services research, rural healthcare delivery, and health outcomes. Dr. Ward has authored more than 100 peer-reviewed journal articles, many of which are highly cited. She has been funded on more than 70 grants and contracts during her research career and has extensive experience directing research teams and conducting evaluations of healthcare implementation and quality improvement projects. She has been involved in telehealth research for nine years. Dr. Ward has two policy briefs and 10 peer-reviewed publications specifically related to telehealth.

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Karisa K. Harland

Associate Research Scientist
University of Iowa Carver College of Medicine

Dr. Harland is as Associate Research Scientist in the Department of Emergency Medicine at the University of Iowa. She has a PhD in Epidemiology from the University of Iowa College of Public Health. Dr. Harland has extensive experience in epidemiologic methods including probabilistic linkage, analysis of state and national secondary datasets, and sophisicated analyses techiniques such as hierarchical regression modeling.

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