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Burn follow-up

An innovative application of telemedicine

Advice on management of burns for primary care physicians

NJ Massman, Department of Surgery, Regions Hospital, St. Paul, MN
JD Dodge, HealthPartners Information Systems, Bloomington, MN
KK Fortman, HealthPartners Research Foundation, Bloomington, MN
KJ Schwartz, Burn Rehabilitation, Regions Hospital, St. Paul, MN
LD Solem, Department of Surgery, Regions Hospital, St. Paul, MN

Summary

This study assesses the efficiency and effectiveness of burn consultations via telemedicine. The Burn Center maintains a database which records information concerning each patient’s burn telemedicine visits. From this database, information on time and travel costs was abstracted and evaluated for this study. Telemedicine burn consultations are cost effective for the patient, however are more time consuming for the physician and therapist. As the remote sites become more familiar with preparing patients for their visits, telemedicine will become more efficient for the physician while remaining cost effective for the patient.

Introduction

Application

Burn patients frequently require prolonged follow-up care after injury. Follow-up care is typically an outpatient visit in The Burn Clinic (face-to-face physician-patient encounter) where they are seen by a physician and burn therapist and by the clinical psychologist when indicated. The follow-up visits are initially scheduled 7–14 days after discharge and then every one to two weeks for the next two months, finally every month for about three months and then every three months until their hypertrophic scar matures and they no longer need compression garments (usually a period of 12–24 months).

During the clinic visit, the patient is evaluated for healing (remaining open areas or new open areas in their recently healed fragile epithelium), burn contractures which impair range-of-motion, maturation of hypertrophic scar, reintegration into society, return-to-work or return-to-school, psychological well-being and the fitting of garments and splints.

Burn Center background

The Burn Center at Regions Hospital in St. Paul, MN, is an 18-bed facility established in 1963. The Burn Center serves a large geographic area including Iowa, Minnesota, Montana, North Dakota, South Dakota and Wisconsin. Patients travel distances of up to 1,360 miles (2,189 kilometers) round-trip for their follow-up care.

Methods

Technical approach

A “dial up, open network” system is used by Regions Hospital rather than a “dedicated” or “closed” network. This open network allows the flexibility to serve many facilities with differing systems, running at a 128kb–1.4kb data rate with the majority of calls at 384kb. Regions Hospital physicians have conducted more than 950 telemedicine visits at the 384kb rate and are pleased with the quality. By transmitting at 384kb, it is possible to hold three concurrent medical visits over one T1 line.

TM burn consults

The Regions Hospital Burn Center completed 87 follow-up visits with 40 patients via telemedicine from March 1997 through August 1998. These consultations involved burn physicians, occupational therapists and a clinical psychologist. Patients were seen at 15 telemedicine sites in six states (Minnesota, Iowa, Montana, North and South Dakota and Wisconsin).

Table 1 summarizes the patient demographic data. Historically 80 percent of the Burn Center’s patient population is male and under age 30. In this study, the proportion of males is slightly higher (93 percent males (n = 37)), and the patient population is slightly older.

Table 1 patient demographics (n = 40)

  Mean Range
Age 29 1–71
Total Body Surface
Area (TBSA = bum
size)
18 percent 176 percent

Results


Table 2 summarizes distances traveled, associated costs and cost savings calculated per patient. Mileage cost is based on 1998 Internal Revenue Standards (IRS) at US $.325/mile (US $.202/kilometer). The total number of telemedicine visits (n=87) was divided by the patient population (n = 40) to calculate the average number of telemedicine follow-up visits per patient (n = 2.175). This number is used to calculate total travel and cost savings data per patient.

Table 2 Round trip travel costs and savings per patient (n = 40), extended to include total telemedicine consultations (n = 87) and total program savings.

Travel Mean (per patient n = 40) Range Mean (total follow-up visits n = 2.175)
Between Burn Center and patients’ homes *travel(miles/kil) *cost 687/1,106 $223 110-1,360/1772-2,189 1,495/2,406 $486
Between telemedicine facilities and patients’ homes *travel(miles/kil) *cost 115/185 $37 0-541/0-871 250/402 $81
Savings *travel *cost savings 572/921 $186   1,245/2,004 $405
Total Program Savings *Travel(miles/kil) *Savings 49,804/80,152 $16,186    



Table 3 summarizes burn areas evaluated. The patients are evaluated for healing (open areas), range-of-motion, overall physical well-being, ability to return-to-work or school, need for further therapy and home cares and fitting of compression garments.

No. of patients


Table 3 Burn areas evaluated (n = 40 patients)


Arms
26
Hands
20
Lower Extremities
19
Trunk
19
Neck
16
Head
12
Face
9
Back
3

Regions Hospital supports a regional telemedicine network, which means it supports facilities outside the Regions/HealthPartners network. Major benefits to a regional network include:

  1. Creates better access to health care for rural and underserved areas
  2. Saves travel time and money for providers and patients
  3. Improves patient care through improved access
  4. Gives physicians better access to tertiary consultation

Limitations

In the United States, several issues currently exist inherent to any telemedicine program, i.e., medical licensure, credentialing, reimbursement and intrastate and interstate infrastructure issues. Additionally, problems specific to the practice of burn therapies exist.

During a live clinic visit, the physician and therapist will palpate the healed burn and evaluate thickness and firmness of the scar. This is not possible via telemedicine, but scar thickness can be evaluated by using a good still photograph or using the document camera to provide a high-quality image of specific areas. Experience with telemedicine allows the physician and therapist to make better judgments about the maturation and smoothness of the burn scar.

Transparent face masks and neck splints, used for scar control, were initially developed at Regions by Elizabeth Rivers1 and are now used internationally. Modification of these splints must be done on a regular basis and can only be done with the specially-trained therapist and the patient together in the same room. Other splints are less unique and may be able to be modified by a therapist practicing near the patient’s home.

Compression garments, although somewhat controversial2, remain a mainstay in Regions’ treatment of hypertrophic scar. These garments are fitted by therapists and can be evaluated either locally or via telemedicine.

Inefficiencies

Telemedicine burn consultations generally take longer than face-to-face physician-patient encounters. In face-to-face encounters, nurses remove dressings and garments of one patient while the specialist is seeing another patient. When patients are seen via telemedicine, the specialist must wait while the patient undresses or has dressings removed. Telemedicine visits also take longer to obtain adequate camera shots whereas in face-to-face visits the specialist(s) can simply look at the areas needing evaluation while simultaneously interviewing the patient.

Technical problems (inadvertent cutoffs, difficulty switching from site-to-site) lead to down times. In addition, many remote sites are not set up as examining rooms, resulting in an environment which is not conducive to patient evaluations.

Conclusions

Burn follow-up can be successfully completed via telemedicine. From the patient perspective, dramatic savings in time, travel and expense are experienced.

However, burn physicians and therapists have found that telemedicine consultations are less efficient than face-to-face physician-patient encounters; at least twice as many patients can be seen face-to-face during the same time period.

Telemedicine equipment is available in a large number of communities in the Regions Hospital referral area. However, it is rarely used for emergency consultations: (1) many of the systems only have personnel to staff facilities Monday–Friday (excluding evenings, weekends and holidays) and (2) some switching sites are available only during weekday work hours.

Acute burn consultations are a very new concept and have not been publicized to physicians and emergency rooms in many communities with telemedicine capabilities. As telemedicine becomes more widely utilized, some of he barriers to acute consultations may gradually be overcome.

Acknowledgements: We would like to thank the following sites for allowing us to evaluate and care for their patients: Austin Medical Center (via Mayo Clinic), Austin, MN; Community Memorial Hospital (Via Gunderson), Winona, MN; Glendive Medical Center (via Easter Montana Telemedicine Network), Glendive, MT; Gunderson Lutheran Hospital, LaCrosse, WI; Indian Health Services, Sisseton, SD; Mayo Clinic, Rochester, MN; McKenzie County Memorial Hospital (Via MedCenter One), Watford City, ND; MedCenter One Health Systems, Bismarck, ND; Merit Care Hospital, Fargo, ND; North Iowa Mersy Health Center, Mason City, IA; Rapid City Regional Hospital, Rapid City, SD; Sacred Heart Hospital, Yankton, SD; Sidney Health Center (via Easter Montana Telemedicine Network), Sidney, MT; Sioux Valley Hospitals & Health System, Sioux Falls, SD; and St. Lukes TriState Hospital (via MedCenter One), Bowman, ND.

References

  1. Shons AR, Rivers, EA and Solem LD. A rigid transparent face mask for control of scar hypertrophy. Ann Pl Surg 6:245-248, 1981
  2. Kealey GP, Jensen KL, Laubenthal KN and Lewis RW. Prospective randomized comparison of two types of pressure therapy garments. J Burn Care & Rehab 11:334-336, 1990