Lisa Blom

Image-based medical expert teleconsultation in acute care of injuries : a systematic review of effects on information accuracy, diagnostic validity, clinical outcome, and user satisfaction

Objective To systematically review the literature on image-based telemedicine for medical expert consultation in acute care of injuries, considering system, user, and clinical aspects. Design Systematic review of peer-reviewed journal articles. Data sources Searches of five databases and in eligible articles, relevant reviews, and specialized peer-reviewed journals. Eligibility criteria Studies were included that covered teleconsultation systems based on image capture and transfer with the objective of seeking medical expertise for the diagnostic and treatment of acute injury care and that presented the evaluation of one or several aspects of the system based on empirical data. Studies of systems not under routine practice or including real-time interactive video conferencing were excluded. Method The procedures used in this review followed the PRISMA Statement. Predefined criteria were used for the assessment of the risk of bias. The DeLone and McLean Information System Success Model was used as a framework to synthesise the results according to system quality, user satisfaction, information quality and net benefits. All data extractions were done by at least two reviewers independently. Results Out of 331 articles, 24 were found eligible. Diagnostic validity and management outcomes were often studied; fewer studies focused on system quality and user satisfaction. Most systems were evaluated at a feasibility stage or during small-scale pilot testing. Although the results of the evaluations were generally positive, biases in the methodology of evaluation were concerning selection, performance and exclusion. Gold standards and statistical tests were not always used when assessing diagnostic validity and patient management. Conclusions Image-based telemedicine systems for injury emergency care tend to support valid diagnosis and influence patient management. The evidence relates to a few clinical fields, and has substantial methodological shortcomings. As in the case of telemedicine in general, user and system quality aspects are poorly documented, both of which affect scale up of such programs.

Epidemiology of fatal burns in rural South Africa: A mortuary register-based study from Mpumalanga Province

AIM The study investigates the epidemiology of fatal burns in the predominantly rural province of Mpumalanga, South Africa. METHOD The study is cross-sectional and investigates region specific data extracted from a National Injury Mortality Surveillance System (NIMSS) and originally gathered at mortuaries. Fatal burns sustained during the 2 year period 2007 and 2008 are analysed (n=304 cases). Mortality rates by age group, sex and district were compiled and attention was paid to manner of death, location, and temporal characteristics (time of day, weekday, season). RESULTS The overall fatal burn rate was 3.8 per 100,000 inhabitants (95% CI 3.4-4.3). The highest rates were among the oldest age group (8.2/100,000; 95% CI 6.1-10.7), males (5.3/100,000; 95% CI 4.6-6.2) and in one of the three districts, Nkangala (4.8/100,000; 95% CI 3.9-5.6). Most burns were accidental (68.4%) and intentional ones (13.5%) occurred in particular among older people and in the home. Burns were sustained frequently at home (55.6%), between midnight and 5a.m. and towards the end of the week. Seasonal variations were more pronounced in Nkangala. CONCLUSIONS Fatal burns could be less common in rural than urban South Africa. As in urban South Africa, however, older people, young children, and males are more at risk. Not surprisingly, the occurrence of fatal burns is strongly related to living conditions and lifestyle, which vary even within rural areas of South Africa.

Gender differences in burns: A study from emergency centres in the Western Cape, South Africa

INTRODUCTION Little is known about gender differences in aetiology and management of acute burns in resource-constrained settings in South Africa. METHOD This cross-sectional study is based on burn case reports (n=1915) from eight emergency centres in Western Cape, South Africa (June 2012-May 2013). Male/female rate ratios by age group and age-specific incidence rates were compiled for urban and rural areas along with gender differences in proportions between children and adults for injury aetiology, burn severity, length of stay and patient disposition. RESULTS Children 0-4 years in urban areas had the highest burn incidence but only among adults did male rates surpass females, with fire burns more common among men 20-39 years and hot liquid burns among men 55+ years. Men had a higher proportion of burns during weekends, from interpersonal violence and suspected use of alcohol/other substances, with more pronounced differences for hot liquid burns. Despite similar Abbreviated Injury Scale (AIS) scores, men were more often transferred to higher levels of care and women more often treated and discharged. CONCLUSION Burns were far more common among children although gender differences arose only among adults. Men sustained more injuries of somewhat different aetiology and were referred to higher levels of care more often for comparable wound severity. The results suggest different disposition between men and women despite similar AIS scores. However, further studies with more comprehensive information on severity level and other care- and patient-related factors are needed to explore these results further.

A review of primary and secondary burn services in the Western Cape, South Africa : research

BACKGROUND In 2011, the Department of Health of the Western Cape Province, South Africa, requested a review of current burn services in the province, with a view to formulating a more efficient and cost-effective service. This article considers the findings of the review and presents strategies to improve delivery of appropriate burn care at primary and secondary levels. METHODS Surveys were conducted at eight rural and urban hospitals, two outreach workshops on burn care, four regional hospitals and at least 60 clinics in Cape Town and in the Western Cape as far as Ladismith. A survey on community management of paediatric burns was also included in the study. RESULTS The incidence of burns was highest in the winter months, more than half of those affected were children, and the majority of burns were scalds from hot liquids. Most burn injuries managed at primary level were minor, with 75% of patients treated by nurse practitioners and discharged. The four regional secondary hospitals managed the majority of moderate to severe burns. There is room for improvement in terms of treatment facilities and consumables at all levels, regional hospitals being particularly restricted in terms of outdated equipment, a shortage of intensive care unit beds, and difficulties in transferring patients with major burns to a burns unit when indicated. CONCLUSION The community management of paediatric burns was satisfactory, although considerable delays in transfer and insufficient pain control hampered appropriate care. A great need for ongoing education at all levels was identified. Ten strategies are presented that could, if implemented, lead to tangible improvements in the management of burn patients at primary and secondary levels in the Western Cape.

Expectations of medical specialists about image-based teleconsultation – A qualitative study on acute burns in South Africa

Background Image-based teleconsultation between medical experts and healthcare staff at remote emergency centres can improve the diagnosis of conditions which are challenging to assess. One such condition is burns. Knowledge is scarce regarding how medical experts perceive the influence of such teleconsultation on their roles and relations to colleagues at point of care. Methods In this qualitative study, semi-structured interviews were conducted with 15 medical experts to explore their expectations of a newly developed App for burns diagnostics and care prior to its implementation. Purposive sampling included male and female physicians at different stages of their career, employed at different referral hospitals and all potential future tele-experts in remote teleconsultation using the App. Positioning theory was used to analyse the data. Results The experts are already facing changes in their diagnostic practices due to the informal use of open access applications like WhatsApp. Additional changes are expected when the new App is launched. Four positions of medical experts were identified in situations of diagnostic advice, two related to patient flow–clinical specialist and gatekeeper–and two to point of care staff–educator and mentor. The experts move flexibly between the positions during diagnostic practices with remote colleagues. A new position in relation to previous research on medical roles–the mentor–came to light in this setting. The App is expected to have an important educational impact, streamline the diagnostic process, improve both triage and referrals and be a more secure option for remote diagnosis compared to current practices. Verbal communication is however expected to remain important for certain situations, in particular those related to the mentor position. Conclusion The quality and security of referrals are expected to be improved through the App but the medical experts see less potential for conveying moral support via the App during remote consultations. Experts’ reflections on remote consultations highlight the embedded social and cultural dimensions of implementing new technology.

What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care

BackgroundTraumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology.MethodsThis qualitative study investigated tele-experts’ (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis.ResultsExperts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback.ConclusionExperts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success – time pressure, intensity and the wide range of subspecialties to be considered.

Accuracy of acute burns diagnosis made using smartphones and tablets: a questionnaire-based study among medical experts

BackgroundRemote assistance for burns by medical experts can support nurses and general physicians in emergency care with diagnostic and management advice. Previous studies indicate a high diagnostic accuracy based on images viewed on a computer screen, but whether image-based analysis by experts using handheld devices is accurate remains to be determined.MethodA review of patient data from eight emergency centres in the Western Cape, South Africa, revealed 10 typical cases of burns commonly seen in children and adults. A web-based questionnaire was created with 51 images of burns representing those cases. Burns specialists from two countries (South Africa and Sweden (n = 8 and 7 respectively)) and emergency medicine specialists from South Africa (n = 11) were contacted by email and asked to assess each burn’s total body surface area (TBSA) and depth using a smartphone or tablet. The accuracy and inter-rater reliability of the assessments were measured using intraclass correlation coefficients (ICC), both for all cases aggregated and for paediatric and adult burn cases separately. Eight participants repeated the questionnaire on a computer and intra-rater reliability was calculated.ResultsThe assessments of TBSA are of high accuracy all specialists aggregated (ICC = 0.82 overall and 0.81 for both child and adult cases separately) and remain high for all three participant groups separately. The burn depth assessments have low accuracy all specialists aggregated, with ICCs of 0.53 overall, 0.61 for child and 0.46 for adult cases. The most accurate assessments of depth are among South African burns specialists (reaching acceptable for child cases); the other two groups’ ICCs are low in all instances. Computer-based assessments were similar to those made on handheld devices.ConclusionAs was the case for computer-based studies, burns images viewed on handheld devices may be a suitable means of seeking expert advice even with limited additional information when it comes to burn size but less so in the case of burn depth. Familiarity with the type of cases presented could facilitate image-based diagnosis of depth.

842 Gender differences in burns management: a cross-sectional study from emergency centres, South Africa

Background Gender differences have been reported both in exposure to and outcome of burn injuries. Whereas the general gender distribution of burns is relatively well known, few studies have examined gender differences in incidence and management of burns for different burn mechanisms in sub-Saharan Africa. Methods The study is cross sectional and based on case reports of patients seeking care for a burn injury at Emergency Centres in eight health care facilities in the Western Cape Province, South Africa between June 2012 and May 2013 (n = 1915). Gender specific incidence rates were compiled for age groups 0–4, 5–9, 10–14, 15–19, 20–54 and 55+. Differences in proportions in men and women were examined for AIS, length of stay and disposition. All analyses were stratified by burn mechanism. Results Children 0–4 years have the highest incidence of burns with boys and girls relatively equally affected. Gender differences in burn incidence are found in ages 20 years and older. Men 55 years and older have a higher risk compared to women for hot liquid burns whereas men aged 20–54 have a higher risk of fire burns. While no gender differences in children are observed in injury management, adult men are significantly more transferred than women (all burn mechanisms aggregated) while women with both hot liquid and fire burns are treated as outpatients to a higher extent. No gender difference in AIS or length of stay are found among adults. Conclusions Even though burn incidence is highest among children, gender differences in burn incidence and management are mainly visible in adults. Results about men being transferred and women treated as outpatients to a higher extent in spite of similar AIS raise the question of hidden gender biases in the healthcare.