Efficacy of Telemedicine Programs: Facts vs Fiction

Protocols for Telemedicine Patient Exam

Telemedicine Specialist Examine: 

Vital signs

• Heart rate
• Blood pressure
• Oxygen level

Head & Neck

• Eyes, Ears, Nose, etc
• Abdomen
• Cardiac & Pulmonary (e-Stethoscope)
• Neurological

On-Site Nurse Performs:

• Neck & Gland Palpate
• Abdominal Palpate
• Back/Spine Palpate
• Musculoskeletal

Physical exam: At bedside, the Specialist sees and communicates with the patient. Using the zoom feature, the Specialist can focus on eyes, ears, nose. All bedside monitors are visible showing vital signs. An on-site nurse will assist with e-stethoscope, facilitating cardiac, abdominal and back/spine palpate, and musculoskeletal exam. Specialist will also perform a neurological exam, as needed.

Palpating the abdomen: Eagle’s high-tech blue-tooth stethoscope serves as a form of palpation when applied correctly, and will correlate with the patient’s self-reported symptoms, like tenderness. The on-site RN receives training in utilizing the e-stethoscope and will supplement by performing a deeper palpation exam. The Specialist can confirm the exam with the Emergency physician.

Neurological Exam: While the TeleNeurologist closely monitors the face, the patient responds by raising their eyebrows, puffing out their cheeks, giving a big smile, as we look for facial symmetry, cranial nerve deficits, etc.

The on-site nurse assists with shoulder resistance, upper and lower extremity resistance; this will be confirmed with the ER physician’s examination.

The TeleNeurologist may also assess short-term memory recall, by holding up a picture or an object; the patient’s response shows comprehension level.

A complete assessment: The physical examination is very complete, assessing heart, lungs, abdomen, neuro, and skin (via special attachments); the cart may also have an otoscope or an ophthalmoscope attachment.

Telemedicine facilitates a high level of multidisciplinary care. All specialists and on-site caregivers are focused on delivering optimal care. On-site nurses work at a high level of competency, and receive advanced training in virtual diagnoses. This collaboration results in best practices in medical care.

#4 Telemedicine programs can’t perform procedures – FACT 

It’s true. A remote provider can’t reach out and physically touch a patient. Robotic surgical procedures now being performed in hospitals are not applicable to telemedicine.

FACT: Eagle takes a multidisciplinary approach in assessing and preparing the patient for transfer or for surgery — which is achieved in a very timely manner. The on-site healthcare providers become the Specialist’s hands.

While an Eagle Specialist might not be physically present, they have the skills to make non-physical connections occur rapidly and effectively.

EXAMPLE: In an urgent situation, when a patient is experiencing respiratory arrest (breathing has stopped), our Specialist will call the ER physician: “Hey, this has been going on, this patient’s working really hard to breathe, their blood gas shows acidosis, they’re hypoxic, they’re hypercarbon, we’ve had them on bypass or they’re not a bypass candidate for this and that reason, I feel they need to be intubated, here’s the imaging result…”

The Eagle Specialist sees the patient’s imaging and the chart. They see the patient, and the patient sees them. The Emergency physician or another team member is in the room. This cohesive team works very efficiently and effectively in providing patient care.

With all the data available to the Specialist, the best decisions can be made. Having developed a trusting relationship with on-site providers, including the ER physician and anesthesiologist, the team can move very quickly to next steps.

EXAMPLE: A COVID-19-infected patient had an urgent finding in their chest x-ray. It was pretty rare, so the Specialist pulled up the EMR — with the patient also on the screen. The Specialist examined the chest x-ray, the lab results, and notes from admission. This confirmed the new finding, at 2 a.m. in a rural Oregon hospital.

The Specialist called the hospital supervisor, alerted them that intubation and transfer were necessary. This patient had to be airlifted to another hospital, with a local certified anesthesiologist with them.

The hospital’s on-site respiratory therapist performed the intubation; a radiology technician was also present. The Specialist could confirm the tube was in the correct position (via real-time x-ray). The respiratory therapist prepared the blood gas within a few minutes.

The Specialist assessed oxygenation and ventilation on that patient. Adjustments were made to the ventilator and updates were provided to the tertiary hospital: “Hey. We’ve intubated this patient; it’ll be two hours until they get there; this is the blood gas; they’re sedated and ready for you.”

This is a perfect example of care coordination, bringing together all information and healthcare teams to perform effectively in providing patient care.

Common Scenarios

Atrial Fibrillation: This is a common call for the hospitalist and in telemedicine we see it fairly commonly across the nation. This can be managed easily by an experienced hospitalist or experienced physician, checking the EKG and ordering the medication.

The Specialist needs to see the patient. The robot cart is pulled into the room. The patient’s rhythm is visible on the heart monitor; the Specialist can confirm it with the EKG, check oxygenation, and ask, “Hey, are you having any chest pain? Are you having any symptoms?” Just that brief interview allows the Specialist to assess encephalopathy or pulmonary edema, if there’s chest pain.

The bluetooth stethoscope allows the Specialist to listen for crackles and diminished heart sounds while waiting on further imaging (chest x-ray) that’s been ordered. This can be assessed in the room via the radiology monitor.

If SVT is present, the team can administer a different therapy other than a beta blocker or a calcium channel blocker. With an SVT, they would administer adenosine. If there’s a cardioversion required for a shock-like state, and the patient is a candidate for cardioversion, the Specialist can facilitate that with the Emergency physician.

Coordinated Team Effort: This case illustrates how a Specialist can coordinate with the on-site team to have all components in place for patient care. The appropriate labs and tests ordered and assessed, and results available on the EMR. The patient is within view, and all monitors are visible.

When appropriate on-site team members are assembled, and all test results are in the EMR, the Specialist can lead the patient care. The Specialist is indeed in the patient room, providing clear guidance to each team member to carry out procedures, as needed. There is continuity in the process, and optimal patient care is delivered.

Code Sepsis: A Specialist can also handle Code Sepsis. The on-site physician will assess the patient, review their chart, look for a sepsis order, and update the sepsis score. At that point, they contact the Specialist to alert them about this condition. With the COVID-19 pandemic, our telemedicine programs have encountered an uptick in sepsis cases.

If the sepsis order is in place, that quality metric has been established. If the order is not in place, and the patient meets sepsis criteria, the Eagle Specialist must enter the sepsis order set.

The protocol: The Eagle Hospitalist will perform a detailed review of the chart, ensuring antibiotics and fluids. We will reassess the six-hour bundle for reperfusion. We will ensure the patient has met those quality metrics. We will follow up with the nurse: “Hey. What’s going on? Do you see a huge clinical difference?”

If the nurse advises, the Specialist will see the patient at the bedside, assessing the patient. The Specialist can examine their skin, identify changes in lower extremities, assess perfusion by asking the nurse to touch the patient’s fingertips. The Specialist will check capillaries, medications, both cardiac and lung exams to assess need for further images, testing, antibiotics.

Overview of Responsibilities: Specialist & On-Site Provider

INTUBATION: Tele-ICU & Telemedicine Specialist work with onsite staff to:

• Intubate a patient by coordinating with an Emergency Department physician or anesthesiologist.
• Set and manage ventilator settings with the support of IC nurses

ATRIAL FIBRILLATION: Telemedicine physicians work with onsite staff to:

• Telemedicine providers detect A-fib by listening to the patient’s heart or by electronically monitoring the patient’s pulse
• Electrocardiogram (ECG) or echocardiogram are accessible via secure transmission to the telemedicine physician, which allows the virtual provider to identify any signs of A-fib

SEPSIS: Telemedicine physicians work with onsite staff to diagnose and treat sepsis patients:

• Specialists receive real-time data about the patient’s vital signs, lab tests and radiographic findings. Video and audio capabilities during a patient consult allow the Specialist to “beam in,” examine and communicate with the patient.
• Requests for further patient analysis via seroradiographic testing are sent directly from the Specialist to the hospital’s EMR. Once diagnosed, the Specialist can order antibiotics, intravenous fluids, transfer to the ICU, or order any appropriate treatment using the same process.

#5 You can’t manage a Code Blue using telemedicine – FICTION

We’re very proud of our Code Blue record. As we all know, a Code Blue can be tragic. But every time we’re called, our Specialists have effectively managed Code Blue working with the on-site team. This is typically a night shift call, when the hospital has limited resources. Our Specialists effectively take charge of the situation and deliver effective rapid-response patient care.

Every hospital has a Code Blue response protocol in place. The team leader is not always a physician. In other cases, the Specialist team is called to be the primary leader or the Code Runner.

On-Site: When a Code Blue is Announced

Eagle Telemedicine programs have a specific protocol for notifying team members. In the hospital, the announcement is announced in the public address system.

The nearest nurses will initiate the first resuscitation efforts. The Specialist or intensivists will beam onto a cart. In some cases, the Specialist appears before the cart gets into the room. A flash will appear on hospital walls and doors as the cart/Specialist is rushed down the hallway and pushed into a room.

When the Specialist arrives at the Code scene, an emergency physician is often present. In other cases, there may be another hospital staff member. The Specialist will relieve them of their duty, expressing confidence in handling the situation. As needed, we will ask an Emergency physician to assist with an intubation or a line.

At the Patient’s Bedside

• Patient’s left foot: The Specialist is at the patient’s left foot, where the Code Blue leader would stand. The Specialist watches both the remote and bedside heart monitors to assess patient’s heart rhythm.
• The Specialist calls out the orders to each team member. Teamwork is delivering care; the Specialist is leading the Code.
• On the left side: Two carotid checkers. The medication pusher. The CPR thumper. Team member to document the events/process.
• On the right side: Two carotid pulse checkers; they will administer CPR, putting hands on the carotid pulse to advise of pulse presence.
• At the patient’s head: The anesthesiologist or respiratory therapist. Ready for bag masking, placing an endotracheal tube, and assessing capnography.

That’s how a Specialist runs a Code Blue. They follow ACLS protocol, making sure to follow standards for high-quality CPR, with or without the CPR thumper.

Best Practices for Code Management

Managing a Code requires optimal placement of resources within a room. As we work with hospitals to implement programs, we spend considerable time on specific workflows — ensuring everybody understands their role in certain situations and events.

It’s extremely important to have the utmost clarity on roles in these situations. We run mock Codes to ensure this — and to familiarize each team member with Code management. We debrief afterwards – what worked, what didn’t work. We make changes and we run again. We practice for a reason, because we want zero mistakes.

After the care is ultimately directed and performed, the Specialist will facilitate the appropriate documentation in the EMR. Indeed, the Specialist/telemedicine can effectively manage and deliver care for Code Blues and Rapid Responses — and do so with the highest quality outcomes.