Lawrence P A Burgess

Developing Next-Generation Telehealth Tools and Technologies: Patients, Systems, and Data Perspectives

The major goals of telemedicine today are to develop next-generation telehealth tools and technologies to enhance healthcare delivery to medically underserved populations using telecommunication technology, to increase access to medical specialty services while decreasing healthcare costs, and to provide training of healthcare providers, clinical trainees, and students in health-related fields. Key drivers for these tools and technologies are the need and interest to collaborate among telehealth stakeholders, including patients, patient communities, research funders, researchers, healthcare services providers, professional societies, industry, healthcare management/economists, and healthcare policy makers. In the development, marketing, adoption, and implementation of these tools and technologies, communication, training, cultural sensitivity, and end-user customization are critical pieces to the process. Next-generation tools and technologies are vehicles toward personalized medicine, extending the telemedicine model to include cell phones and Internet-based telecommunications tools for remote and home health management with video assessment, remote bedside monitoring, and patient-specific care tools with event logs, patient electronic profile, and physician note-writing capability. Telehealth is ultimately a system of systems in scale and complexity. To cover the full spectrum of dynamic and evolving needs of end-users, we must appreciate system complexity as telehealth moves toward increasing functionality, integration, interoperability, outreach, and quality of service. Toward that end, our group addressed three overarching questions: (1) What are the high-impact topics? (2) What are the barriers to progress? and (3) What roles can the National Institutes of Health and its various institutes and centers play in fostering the future development of telehealth?

Teaching mass casualty triage skills using immersive three-dimensional virtual reality.

OBJECTIVES Virtual reality (VR) environments offer potential advantages over traditional paper methods, manikin simulation, and live drills for mass casualty training and assessment. The authors measured the acquisition of triage skills by novice learners after exposing them to three sequential scenarios (A, B, and C) of five simulated patients each in a fully immersed three-dimensional VR environment. The hypothesis was that learners would improve in speed, accuracy, and self-efficacy. METHODS Twenty-four medical students were taught principles of mass casualty triage using three short podcasts, followed by an immersive VR exercise in which learners donned a head-mounted display (HMD) and three motion tracking sensors, one for their head and one for each hand. They used a gesture-based command system to interact with multiple VR casualties. For triage score, one point was awarded for each correctly identified main problem, required intervention, and triage category. For intervention score, one point was awarded for each correct VR intervention. Scores were analyzed using one-way analysis of variance (ANOVA) for each student. Before and after surveys were used to measure self-efficacy and reaction to the training. RESULTS Four students were excluded from analysis due to participation in a recent triage research program. Results from 20 students were analyzed. Triage scores and intervention scores improved significantly during Scenario B (p < 0.001). Time to complete each scenario decreased significantly from A (8:10 minutes) to B (5:14 minutes; p < 0.001) and from B to C (3:58 minutes; p < 0.001). Self-efficacy improved significantly in the areas of prioritizing treatment, prioritizing resources, identifying high-risk patients, and beliefs about learning to be an effective first responder. CONCLUSIONS Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, fully immersed VR triage experience.

Alarm limit settings for early warning systems to identify at-risk patients

AIM This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems. BACKGROUND Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings. METHODS A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003-January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits. RESULTS A total of 317 patients satisfied the inclusion criteria, with 780.71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130-135, low 40-45; respiratory rate high 30-35, low 7-8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow. CONCLUSION Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.

Teaching mass casualty triage skills using iterative multimanikin simulations.

Objective. Effective mass casualty triage requires rapid andaccurate decision making. First responders need to be trained, but opportunities to practice triage andreceive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, andself-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. Methods. Learners initially developed baseline knowledge of MC triage by listening to four short podcasts andpassing a written examination. They then experienced three sequential MC scenarios (A, B, andC) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) andintervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, andtriage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy andreaction to the training. Results. Twenty-one medical students were enrolled and20 students passed the examination. The TS andIS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment andresources, identifying high-risk casualties, andlearning to be an effective first responder. Conclusion. Novice learners demonstrated improved triage andintervention scores, speed, andself-efficacy during an iterative, multimanikin MC training experience

Impact of Continuous Vigilance Monitoring on Nursing Workflow

Background: Increasing nursing time in patient care is beneficial in improving patient outcomes, but this is proving increasingly difficult with the nursing shortage, budgetary constraints, and higher patient acuity. Objective: Nursing workflow was evaluated after the implementation of a continuous vigilance monitoring system to determine if the system enhanced patient-centric nursing care. Methods: Work sampling observations were conducted at 3 hospitals for 6 categories of nursing activities (direct and indirect nursing, documentation, administrative, housekeeping, and miscellaneous) at baseline and at 3 and 9 months. Results: Statistically significant increases in direct (3 months) and indirect nursing care (3 and 9 months) were found, with variability between sites. Statistically significant increases at 3 and 9 months for documentation of patient care activities and decreases in administrative activities were the most consistent findings for all sites. Conclusion: Continuous vigilance monitoring enhanced patient-centric care with increases in direct and indirect nursing care and documentation of those activities.

The Effect of Dynamic Intermittent Hypoxic Conditioning on Arterial Oxygen Saturation

Abstract Background.—Increases in arterial oxygen saturation (SaO2) in response to intermittent hypoxic exposure (IHE) are well established. However, IHE protocols have historically involved static hypoxic environments. The effect of a dynamic hypoxic environment on SaO2 is not known. Objective.—The purpose of this study was to examine the effect of dynamic IHE conditioning on SaO2 using the Cyclical Variable Altitude Conditioning Unit. Methods.—Thirteen trained participants (9 males, age 30.1 ± 9.2 years; 4 females, age 30.3 ± 8.9 years) residing at or near sea level were exposed to a 7-week IHE conditioning protocol (mean total exposure time = 30.8 hours). Participants were exposed to a constantly varying series of hypobaric pressures simulating altitudes from sea level to 6858 m (22 500 feet) in progressive conditioning tiers, creating a dynamic hypoxic environment. SaO2 was evaluated using pulse oximetry (SpO2) 4 times: at 2740, 3360, and 4570 m, prior to and following the first 3 weeks of IHE, and at 4570, 5490, and 6400 m at the start and end of the final 4 weeks. Results.—SpO2 improved 3.5%, 3.8%, and 4.1% at 2470, 3360, and 4570 m, respectively (P < .05), and 3.3%, 3.4%, and 5.9% at 4570, 5490, and 6400 m, respectively (P < .05). At 4570 m, SpO2 increased from 81.7% ± 6.5% to 89.1% ± 3.2% over the entire 7-week conditioning period. Discussion.—The dynamic intermittent hypoxic conditioning protocol used in the present study resulted in an acclimation response, such that SpO2 was significantly increased at all altitudes tested, with shorter exposure times than generally reported.

Familial Recurrent Facial Paresis Four Generations

Recurrent facial palsy is an uncommon idiopathic disorder sometimes associated with the Melkersson-Rosenthal syndrome (MRS) triad of facial palsy, lingua plicata, and facial edema. A family history of facial paresis is identified in some cases, but documented reports involving more than two generations are rare. This report describes four generations of five females with a history of idiopathic hemifacial paresis. Several of the family members had recurrent palsies with the additional symptom of lip edema. Notably, the family pedigree presented does not appear to follow a classic Mendelian inheritance pattern, as illustrated in Fig. 1. This family also has an unusual varicella history that will be described.

Laryngeal Reconstruction Following Vertical Patial Laryngectomy

Laryngeal reconstruction following vertical partial laryngectomy (VPL) with arytenoidectomy was studied in 30 dogs. Variations of a superiorly based thyroid cartilage flap (TCF) were used for reconstruction. In addition, sternohyoid muscle reconstruction and endolaryngeal muscle coverage were studied. Larynges were recovered after a 6-month period in 28 surviving dogs and were analyzed by endoscopic photographs and axial whole-organ sections. Endoscopic assessment (n = 18) demonstrated good results for arytenoid replacement (100%), pseudocord position (94%), pseudocord development (94%), and airway patency (100%). Arytenoid replacement was judged as completely (78%) or partially (22%) replaced. This was accomplished by a pseudocord extending to the cricoid in the horizontal plane. Pseudocord position was judged as normal (83%) or paramedian (11%), with the remainder lateralized (6%). Pseudocord development was judged as complete (72%) or partial (22%), with the remainder poor (6%). Reviewing both endoscopic photographs and gross sections (n = 28), airways were all normal without laryngeal or tracheal stenosis. Histologic assessment (n = 24) also demonstrated good results for arytenoid replacement (79%), pseudocord position (87%), and TCF survival in the glottic plane (79%). Arytenoid replacement was judged as complete (62%) or partial (17%), with the remainder poor (21%). Pseudocord position was judged as normal (50%) or paramedian (37%), with the remainder lateralized (13%). TCF survival was judged as total (63%) or partial (16%). Although not present in the glottic plane in the remaining cases (21%), a portion of the TCF was always present in the supraglottic region. The TCF was largely replaced by bone in the region of the pseudocord, and was covered by nonkeratinizing stratified squamous epithelium and a thick fibrous layer. Breakdown over the TCF was infrequent, with a small focus of granulation tissue over cartilage present in 1 (4%) of 24 cases. Clinically insignificant granulation tissue was present in a total of 6 (25%) cases. In the other 5 cases, this was over muscle or over permanent sutures. Focal cartilage necrosis was present in 2 (8%) of 24 cases, and was localized, self limiting, and deep to the endolaryngeal surface. When the TCF failed to survive histologically, poorer results for arytenoid replacement and pseudocord position generally resulted. However, this apparent difference was not statistically significant due to small sample sizes and variability in results. Other factors that may have kept this difference from becoming larger were thought to be contraction of th e normal cord towards the operated side with fore-shortening of the glottis, and medial rotation and ossification of the posterior thyroid ala remnant.(ABSTRACT TRUNCATED AT 400 WORDS)

Telemedicine in otolaryngology: implications, pitfalls, and roadblocks

The largest obstacle to telemedicine deployment is the lack of well controlled studies validating the safety and efficacy of this type of physician-patient encounter. These studies will eventually lead to clinical acceptance and the codes for reimbursement. The second largest obstacle for telemedicine is validating the change from live, three-dimensional viewing to a two-dimensional image on a monitor. In otolaryngology, video protocols need to be standardized for flexible nasopharyngolaryngoscopy and laryngostroboscopy. Because these are already commonly viewed on a two-dimensional monitor in the live setting, reimbursement could follow for these portions of the examination in a store-and-forward format. Viewing images of the tympanic membrane will be more challenging because the resolution of binocular microscopy will be difficult to duplicate. However, if telemedicine images can safely determine the difference between a normal and abnormal tympanic membrane, patients with an abnormal image can be triaged for a live visit.

Assessing the real-time cognitive capabilities of first responders using emerging technologies in manikin simulators

Medical triage can be a highly stressful situation in which decisions and task performance may have life or death consequences. Individual responses in stressful situations may affect task performance. Increased injury or casualties may occur without proper training and competency of the firstresponder. The emerging technologies of advanced manikin simulators have afforded anatomic, physiological, and pharmacologic realism, which can be dynamically programmed in real-time. This has increased the capabilities and realism of manikin simulations, thus allowing advanced learning techniques that were not previously possible. By employing physiological measures of the learner to determine areas of overwhelming task complexity, which may degrade performance, a method such that the training can be adjusted to the real-time cognitive needs/load of the learner (adaptive scaffolding) can be applied. This has the potential to enhance learning and human data processing in medical triage training.