Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients

Rifat Latifi; Fatos Olldashi; Agron Dogjani; Erion Dasho; Arian Boci; Ayman El-Menyar

doi:10.1016/j.wneu.2018.01.146

Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients

Rifat Latifi, Fatos Olldashi, Agron Dogjani, Erion Dasho, Arian Boci, Ayman El-Menyar

Research output: Contribution to journal › Article › peer-review

13 Scopus citations

Abstract

Background: Use of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania. Methods: A retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed. Results: Of the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital. Conclusion: Telemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.

Original language	English (US)
Pages (from-to)	e747-e753
Journal	World neurosurgery
Volume	112
DOIs	https://doi.org/10.1016/j.wneu.2018.01.146
State	Published - Apr 2018
Externally published	Yes

Keywords

Albania
Low- and middle-income countries
Neurotrauma
Spinal cord injuries
Telemedicine
Traumatic brain injury

ASJC Scopus subject areas

Surgery
Clinical Neurology

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10.1016/j.wneu.2018.01.146

Cite this

@article{eed6982642a145c3b549ddd85ce3b2cc,

title = "Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients",

abstract = "Background: Use of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania. Methods: A retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed. Results: Of the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital. Conclusion: Telemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.",

keywords = "Albania, Low- and middle-income countries, Neurotrauma, Spinal cord injuries, Telemedicine, Traumatic brain injury",

author = "Rifat Latifi and Fatos Olldashi and Agron Dogjani and Erion Dasho and Arian Boci and Ayman El-Menyar",

note = "Funding Information: This study reports a successful application of telemedicine for neurotrauma. To our knowledge, this is one of the first studies to describe a national telemedicine program that has developed a unique teleneurotrauma on call 24/7 for the entire country, using an integrated national telemedicine network, and demonstrates that telemedicine for neurotrauma when structured appropriately and with the participation of all neurosurgeons of the department (including neurosurgery residents) is extremely valuable service for the entire country. We report successful halting of unnecessary transfers to the only trauma center, avoiding significant cost. Teleneurotrauma has become a flagship for clinical telemedicine by assisting all regional hospitals with management of TBI and spinal cord injuries. The telemedicine program in Albania, which started in 2009 and was transferred to the Ministry of Health of Albania in January 2017, was created by the International Virtual e-Hospital Foundation (IVeH) and led by the senior author (R.L.) through a collaborative effort among the U.S. Agency for International Development/Albania, the U.S. Army Corps of Engineers, academia (University of Arizona, Department of Surgery), and the government of Albania, using the principles of the “Initiate Build Operate Transfer” approach. 17 The Albania telemedicine program was conceived, structured, planned, developed, and implemented based on the model that was initially applied in Kosova 21 and subsequently deployed to Cabo Verde. 22 Using the Initiate Build Operate Transfer model, the IVeH established the Integrated Telemedicine and e-Health Program of Albania, which has expanded to 28 hospitals and clinical specialty centers across the country. The telemedicine program of Albania consists of 5 pillars: 1) nationwide technical infrastructure and network; 2) dedicated human capacity expertise; 3) clinical telemedicine program; 4) virtual education program; and 5) electronic virtual library. We recently reported the first 1065 teleconsultations performed in Albania. 19 Of 974 teleconsultations, the majority were for radiology (55%), neurotrauma (16), and stroke (10%). Asynchronous technology accounted for nearly two thirds of all teleconsultations (63.7%), followed by combined (24.3%) and then synchronous (12.0%). In our preliminary study 19 of all neurotrauma patients managed through the telemedicine program, only 36% were transferred to the National Trauma Center with neurotrauma services for the entire country, saving patients travel time and the health care system associated costs. All teleconsultations were initiated via a teleconsulting mobile web application created by IVeH that was accessed by both referring physicians and neurosurgeons. Other studies have reported the use of telemedicine for head injuries. 22-24 Of patients with minor head injuries who were hospitalized at centers without neurosurgery, the benefits of telemedicine were evident, particularly in elderly patients. 22 The national teleradiology network for neurosurgery in Croatia has sped up patients' treatment and reduced costs substantially. 23 In a multicenter study, telerehabilitation was shown to be of benefit to patients discharged from a spinal cord unit compared with standard care in terms of functional improvement. 24 Despite documented results of telemedicine applications, telemedicine for neurotrauma, as for other clinical disciplines, has some elements that potentially represent serious vulnerability: 1) the buy-in factor: physicians, neurosurgeons, trauma surgeons, referring M.D.s (i.e., emergency medicine physicians or other first physicians who come in first contact with trauma patients; 2) infrastructure and the vision: inability of the country, region, or health care system to invest in the infrastructure, beyond “the camera moment” of initial establishment of the program and/or inability to maintain the “momentum” and keep the champions of neurotelemedicine involved; and finally 3) integration: inability of the health care system to incorporate telemedicine into the fabric of the health care system (i.e., electronic health medical records, budget, policy, and the overall health care strategy). Another important factor to mitigate possible vulnerability is the involvement of the department leadership and/or division/section of neurosurgery and trauma service with the program to ensure full transparency so that proper protocols are in place. Lack of any of these factors may seriously jeopardize the sustainability of the program. The Department of Neurosurgery at the National Trauma Center in Tirana is the only institution that offers neurotrauma care for the entire country of more than 3 million inhabitants. Teleneurotrauma has been established as part of teletrauma, but with a distinctly structured process performed by members of the department, using a low-cost mobile solution created by the IVeH. The streamlined process of telemedicine for neurotrauma works as follows: when a patient with head or spinal cord/vertebral injuries is seen at any regional hospital of the country and requires a neurosurgery consult but without other life-threatening injuries that require immediate transfer to National Trauma Center in Tirana, the neurosurgery team on call is contacted via telemedicine clinical coordinator (on call 24/7). The coordinator will notify the neurosurgery team leader or neurosurgery resident on call that there is a CT scan uploaded (in low-tech solution) to the Health Insurance Portability and Accountability Act−protected website with a short form of a history and physical examination performed at the remote hospital. On the basis of the clinical scenario and clinical suspicion for the injury, the neurosurgeon may decide to complete the consult via store-and-forward and render an opinion that is sent to the referring doctor, or to see the patient on live consultation where he or she can speak to the referring physician, see the patient directly, and speak with the patient and his or her family. Moreover, all neurosurgery attending and neurosurgery residents (always involved in the process) have access to the telemedicine event, as they are notified via the Whats App group chat. This efficient process involves the entire neurosurgery team, and everyone can contribute with an opinion on a particular patient irrespective of their physical location. On the basis of this protocol, 66% of patients did not require transfer to the National Trauma Center (NTC). Via telemedicine, neurosurgeons provided quick services, which were delivered as either synchronous (i.e., live), asynchronous (i.e., store-and-forward), or a combination of the 2 (i.e., live and store-and-forward). In our study the response from the consulting hospital (University Trauma Hospital, Tirana) was obtained in median time of 20 minutes. Furthermore, the asynchronous technology (store-and-forward) accounted for the majority of the teleconsultations. Most of the consultations happened during the day time/working hours. Furthermore, as neurosurgeons at the referral center were able to obtain detailed patient status and images before the patient arrived, the subsequent surgical interventions were carried out much more quickly. This process will probably be refined further as more experience is gained and new technical solutions become available. Managing and reporting on quality control of the services will be of utmost importance in the future. Our study has demonstrated that there may be great benefit to a country-wide teleneurotrauma program; however, in order for telemedicine for neurotrauma to be fully incorporated on a wider basis, there is a need for multi-institutional prospective and validation of the use of telemedicine for this group of patients. Many mild head injuries can be managed by non-neurosurgeons as long as neurosurgery services are available in a timely basis and if they are monitored closely by the trauma team, as demonstrated by Joseph et al. 25 Telemedicine may be a great avenue to support small and remote hospitals when the local infrastructure is in place with remote expertise available. The feasibility, cost-effectiveness, applicability, and safety of remote telemedicine do not need further study, as it has been proven again and again. We see no better place to use telemedicine than for neurotrauma, particularly with the widespread use of CT scans even in smaller hospitals. The Albanian health system should move toward adopting more adequate surveillance systems for neurotrauma that adequately track the magnitude of the problem, populations at high risk, circumstances of injury, most at-risk occupations or activities, and severity and outcome data. Moreover, to facilitate more efficient case tracking, there is a need for an integrated electronic medical records system and adoption of the International Classification of Diseases, which provides specific clinical case definitions for categorizing various types of neurotrauma. In addition, the use of the GCS at admission to all emergency departments would provide a standardized means of classifying neurotrauma cases. Prehospital management should focus on limiting further brain injury by adopting interventions including airway management and prevention of hypoxia, hypocapnia, hypercapnia, and hypotension. 4 The Brain Trauma Foundation guidelines for prehospital management of severe TBI, updated in 2014, advocate early advanced trauma life support in TBI patients 4 ; however, there is still a lack of advanced trauma life support training and certification among Albanian health care providers, even in tertiary hospitals. Publisher Copyright: {\textcopyright} 2018 Elsevier Inc.",

year = "2018",

month = apr,

doi = "10.1016/j.wneu.2018.01.146",

language = "English (US)",

volume = "112",

pages = "e747--e753",

journal = "World Neurosurgery",

issn = "1878-8750",

publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Telemedicine for Neurotrauma in Albania

T2 - Initial Results from Case Series of 146 Patients

AU - Latifi, Rifat

AU - Olldashi, Fatos

AU - Dogjani, Agron

AU - Dasho, Erion

AU - Boci, Arian

AU - El-Menyar, Ayman

N1 - Funding Information: This study reports a successful application of telemedicine for neurotrauma. To our knowledge, this is one of the first studies to describe a national telemedicine program that has developed a unique teleneurotrauma on call 24/7 for the entire country, using an integrated national telemedicine network, and demonstrates that telemedicine for neurotrauma when structured appropriately and with the participation of all neurosurgeons of the department (including neurosurgery residents) is extremely valuable service for the entire country. We report successful halting of unnecessary transfers to the only trauma center, avoiding significant cost. Teleneurotrauma has become a flagship for clinical telemedicine by assisting all regional hospitals with management of TBI and spinal cord injuries. The telemedicine program in Albania, which started in 2009 and was transferred to the Ministry of Health of Albania in January 2017, was created by the International Virtual e-Hospital Foundation (IVeH) and led by the senior author (R.L.) through a collaborative effort among the U.S. Agency for International Development/Albania, the U.S. Army Corps of Engineers, academia (University of Arizona, Department of Surgery), and the government of Albania, using the principles of the “Initiate Build Operate Transfer” approach. 17 The Albania telemedicine program was conceived, structured, planned, developed, and implemented based on the model that was initially applied in Kosova 21 and subsequently deployed to Cabo Verde. 22 Using the Initiate Build Operate Transfer model, the IVeH established the Integrated Telemedicine and e-Health Program of Albania, which has expanded to 28 hospitals and clinical specialty centers across the country. The telemedicine program of Albania consists of 5 pillars: 1) nationwide technical infrastructure and network; 2) dedicated human capacity expertise; 3) clinical telemedicine program; 4) virtual education program; and 5) electronic virtual library. We recently reported the first 1065 teleconsultations performed in Albania. 19 Of 974 teleconsultations, the majority were for radiology (55%), neurotrauma (16), and stroke (10%). Asynchronous technology accounted for nearly two thirds of all teleconsultations (63.7%), followed by combined (24.3%) and then synchronous (12.0%). In our preliminary study 19 of all neurotrauma patients managed through the telemedicine program, only 36% were transferred to the National Trauma Center with neurotrauma services for the entire country, saving patients travel time and the health care system associated costs. All teleconsultations were initiated via a teleconsulting mobile web application created by IVeH that was accessed by both referring physicians and neurosurgeons. Other studies have reported the use of telemedicine for head injuries. 22-24 Of patients with minor head injuries who were hospitalized at centers without neurosurgery, the benefits of telemedicine were evident, particularly in elderly patients. 22 The national teleradiology network for neurosurgery in Croatia has sped up patients' treatment and reduced costs substantially. 23 In a multicenter study, telerehabilitation was shown to be of benefit to patients discharged from a spinal cord unit compared with standard care in terms of functional improvement. 24 Despite documented results of telemedicine applications, telemedicine for neurotrauma, as for other clinical disciplines, has some elements that potentially represent serious vulnerability: 1) the buy-in factor: physicians, neurosurgeons, trauma surgeons, referring M.D.s (i.e., emergency medicine physicians or other first physicians who come in first contact with trauma patients; 2) infrastructure and the vision: inability of the country, region, or health care system to invest in the infrastructure, beyond “the camera moment” of initial establishment of the program and/or inability to maintain the “momentum” and keep the champions of neurotelemedicine involved; and finally 3) integration: inability of the health care system to incorporate telemedicine into the fabric of the health care system (i.e., electronic health medical records, budget, policy, and the overall health care strategy). Another important factor to mitigate possible vulnerability is the involvement of the department leadership and/or division/section of neurosurgery and trauma service with the program to ensure full transparency so that proper protocols are in place. Lack of any of these factors may seriously jeopardize the sustainability of the program. The Department of Neurosurgery at the National Trauma Center in Tirana is the only institution that offers neurotrauma care for the entire country of more than 3 million inhabitants. Teleneurotrauma has been established as part of teletrauma, but with a distinctly structured process performed by members of the department, using a low-cost mobile solution created by the IVeH. The streamlined process of telemedicine for neurotrauma works as follows: when a patient with head or spinal cord/vertebral injuries is seen at any regional hospital of the country and requires a neurosurgery consult but without other life-threatening injuries that require immediate transfer to National Trauma Center in Tirana, the neurosurgery team on call is contacted via telemedicine clinical coordinator (on call 24/7). The coordinator will notify the neurosurgery team leader or neurosurgery resident on call that there is a CT scan uploaded (in low-tech solution) to the Health Insurance Portability and Accountability Act−protected website with a short form of a history and physical examination performed at the remote hospital. On the basis of the clinical scenario and clinical suspicion for the injury, the neurosurgeon may decide to complete the consult via store-and-forward and render an opinion that is sent to the referring doctor, or to see the patient on live consultation where he or she can speak to the referring physician, see the patient directly, and speak with the patient and his or her family. Moreover, all neurosurgery attending and neurosurgery residents (always involved in the process) have access to the telemedicine event, as they are notified via the Whats App group chat. This efficient process involves the entire neurosurgery team, and everyone can contribute with an opinion on a particular patient irrespective of their physical location. On the basis of this protocol, 66% of patients did not require transfer to the National Trauma Center (NTC). Via telemedicine, neurosurgeons provided quick services, which were delivered as either synchronous (i.e., live), asynchronous (i.e., store-and-forward), or a combination of the 2 (i.e., live and store-and-forward). In our study the response from the consulting hospital (University Trauma Hospital, Tirana) was obtained in median time of 20 minutes. Furthermore, the asynchronous technology (store-and-forward) accounted for the majority of the teleconsultations. Most of the consultations happened during the day time/working hours. Furthermore, as neurosurgeons at the referral center were able to obtain detailed patient status and images before the patient arrived, the subsequent surgical interventions were carried out much more quickly. This process will probably be refined further as more experience is gained and new technical solutions become available. Managing and reporting on quality control of the services will be of utmost importance in the future. Our study has demonstrated that there may be great benefit to a country-wide teleneurotrauma program; however, in order for telemedicine for neurotrauma to be fully incorporated on a wider basis, there is a need for multi-institutional prospective and validation of the use of telemedicine for this group of patients. Many mild head injuries can be managed by non-neurosurgeons as long as neurosurgery services are available in a timely basis and if they are monitored closely by the trauma team, as demonstrated by Joseph et al. 25 Telemedicine may be a great avenue to support small and remote hospitals when the local infrastructure is in place with remote expertise available. The feasibility, cost-effectiveness, applicability, and safety of remote telemedicine do not need further study, as it has been proven again and again. We see no better place to use telemedicine than for neurotrauma, particularly with the widespread use of CT scans even in smaller hospitals. The Albanian health system should move toward adopting more adequate surveillance systems for neurotrauma that adequately track the magnitude of the problem, populations at high risk, circumstances of injury, most at-risk occupations or activities, and severity and outcome data. Moreover, to facilitate more efficient case tracking, there is a need for an integrated electronic medical records system and adoption of the International Classification of Diseases, which provides specific clinical case definitions for categorizing various types of neurotrauma. In addition, the use of the GCS at admission to all emergency departments would provide a standardized means of classifying neurotrauma cases. Prehospital management should focus on limiting further brain injury by adopting interventions including airway management and prevention of hypoxia, hypocapnia, hypercapnia, and hypotension. 4 The Brain Trauma Foundation guidelines for prehospital management of severe TBI, updated in 2014, advocate early advanced trauma life support in TBI patients 4 ; however, there is still a lack of advanced trauma life support training and certification among Albanian health care providers, even in tertiary hospitals. Publisher Copyright: © 2018 Elsevier Inc.

PY - 2018/4

Y1 - 2018/4

N2 - Background: Use of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania. Methods: A retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed. Results: Of the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital. Conclusion: Telemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.

AB - Background: Use of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania. Methods: A retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed. Results: Of the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital. Conclusion: Telemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.

KW - Albania

KW - Low- and middle-income countries

KW - Neurotrauma

KW - Spinal cord injuries

KW - Telemedicine

KW - Traumatic brain injury

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DO - 10.1016/j.wneu.2018.01.146

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C2 - 29410169

AN - SCOPUS:85042433643

VL - 112

SP - e747-e753

JO - World Neurosurgery

JF - World Neurosurgery

SN - 1878-8750

ER -

Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients

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