Remote Consultation to Kaikoura
In August 2013 Cathy Hammond, clinical nurse specialist in wound care from Nurse Maude in Christchurch, set up a telemedicine clinic to pilot the concept of providing wound care outreach clinics using telemedicine technology. The reason for exploring this area was to try to find ways of improving access to services for rural communities. Kaikoura is a 2 ½ hour drive from Christchurch, and Cathy was interested in looking at providing support and guidance for their community’s clinicians in a more cost-effective and accessible way.
The opportunity to pilot the service came about following discussions between Cathy, Kaikoura GPs and the team at Mobile Health (founders of the NZ Telehealth Resource Centre). Mobile Health have the equipment needed for such a service and were supportive in piloting a clinic in Kaikoura. Cathy’s goal was to complement rural clinics, where patients could be followed up between visits. She was given the approval of her manager, and identified a nurse champion in Kaikoura who would lead the clinic from the Kaikoura end.
It was agreed that, as this was a trial, it was important to have time to become familiar with the technology. As such, only two patients were selected by the Kaikoura clinicians.
Overall, the pilot demonstrated that telemedicine is a valuable resource to rural clinics. It improves access to specialist services, improves communication and has the potential to increase compliance. It appears it could be a cost effective method to deliver care, although the funding of future clinics was not considered in this pilot and needs further exploration.
“Two similar wounds may require quite different treatments depending on the underlying cause of the wound, and the individual patients health status” says Cathy Hammond. “It can be a very specialised decision, something that is very hard for a rural or remote GP or nurse to make as they may have limited experience in some problems. An incorrect treatment plan is not only difficult and frustrating for the patient, but can make the problem worse, as well as wasting expensive medication and treatments“
Regular monitoring of small and subtle changes to wounds is important so treatment plans can be adjusted accordingly. A video link between Christchurch and Kaikora enabled Cathy Hammond to monitor and adjust treatment plans for a number of patients. “I could view the wounds with magnificent clarity especially when shown on a 50” television. The technology was wonderful, the challenge now is having it more easily accessible for patients and health professionals.
The remote consultation removed the need for travel but treating a persistent skin condition is a team effort so having the family and district nursing teams involved in the reviews also produced a much better clinical outcome for the patient.
The programme will be extended with specialist video equipment being included in the construction of the new $13 million Kaikoura Integrated Family Health Centre.
- Picture quality excellent, able to zoom to assess wound without losing quality of the picture
- Sound clear - "slight time lapse but we all quickly became used to this and made allowances during consultation"
- Patients, relatives and clinicians seemed very comfortable using the technology
- Patients appeared at ease and comfortable in the familiar setting with their regular nurse - "my view is that compliance improved, more so with one of the patients in particular and their relatives"
- Patients said they felt there was better communication between the clinicians - other district nurses were able to join the clinic to see a particular patient
- The teleconsultation saved each patient a five hour round trip
- "I could observe the nurse's technique and provide guidance and teaching"
- Saved on clinician time spent travelling
Several aspects of technology needed to be taken into account in planning the equipment to be used in the pilot.
For Cathy Hammond, a large, high resolution screen was vital as her assessment was visual in nature. At the Kaikoura end, a camera with a large zoom capability and a remote pan, tilt and zoom function was necessary to allow for Cathy to move the camera around the room and zoom in on the patients’ wounds as required. As Cathy would be seated in a room in Christchurch, the camera at her end was not as crucial, although it needed to be capable of high definition video so that the patients in Kaikoura could see her clearly on the television set up at their end.
Clear oral communication was imperative, so both ends were equipped with sensitive microphones capable of picking up the speakers’ voices regardless of if they moved about or not.
As it is vital that telemedicine sessions are conducted over a secure and stable network – not affected by the traffic of other users sharing the network – Mobile Health used its mobile satellite van to establish a secure, two-way private network via satellite between Christchurch and Kaikoura. Their van has dedicated bandwidth assigned to it, ensuring the video and audio quality remain high throughout the consultation. In this case, plans for Kaikoura’s new hospital and facilities include the appropriate connection and equipment for this type of consultation to be carried out independently in the future.
- A Cisco SX20 endpoint with a high definition, 12x zoom camera was chosen. The high zoom capability and remote camera control gave Cathy Hammond complete control over positioning and detail of the image she was seeing.
- The endpoint was connected to a mid-range modern television screen. The size of the TV was not overly important as Cathy would be sitting close to her camera and the patient wouldn’t require the same level of detail as she would. The high definition television still provided excellent image quality from the patient end.
- A Cisco SX20 was also used in Christchurch, with Cisco’s entry-level 4x zoom camera sufficient as Cathy would be sitting close to the camera and no zoom or panning functionality was required by Kaikoura.
- A 50” LED television provided Cathy with a very large, highly detailed image of the patient’s wound.