Consulting Services

John Mitchell, BA (Hons), Dip Ed, M Ed Admin, AFAIM Benjamin Mitchell, BA (Psych.), September 1995

I started off thinking this was a bit of a gadget and a gizmo which wouldn't be very useful. But I have really had my mind turned around because it has made a considerable impact on both the way I practise outpatients management and the way that I keep in contact with patients. Its not just a toy. (Dr. Toby Coates, Renal Dialysis registrar, TQEH)

At the conclusion of the first year of TQEH Renal Dialysis Telemedicine Project, interviews were conducted with the major staff users which highlight a range of uses of the facilities and attitudes of staff regarding the benefits, the potential as well as the limitations of the equipment.

Jayne Carpenter, Clinical Nurse Consultant (CNC) of TQEH Renal Dialysis Unit, finds the best uses of telemedicine are:

• administrative meetings
• communication with the centres regarding patient management
• education, although lack of time militates against this use.

The benefits of the telemedicine facilities are:

• the isolation of satellite centre staff is minimised
• it helps to promote unity among all the staff
• the information is channelled direct to the Clinical Nurse Consultant, not via the "pipeline"
• it facilitates faster decision making.

In her role as CNC, Jayne still feels the need to have face-to-face contact with staff at other sites, particularly as she likes to read body language clues during conversation.

Jayne feels that although the telemedicine facilities are very useful, they will be used effectively if staffing levels are improved and if the equipment can be made easier to use:

It's being adopted well: we've become used to it; its become part of the "scene." But it's not being used as much as it could, which probably reflects our "busy ness" . . . It would be used more frequently if an infra-red panel was available. The rollabout is still too cumbersome. It needs to be easier to move.

One patient out at the satellite centre, a Royal Adelaide Hospital patient, wanted to go to Port Augusta for a holiday so I dialled Port Augusta and introduced the patient to the staff. The patients like the fact that you can actually see the Unit you will be using temporarily and meet the staff face to face, before you visit.(Julie Meyer, Project Officer)

Anne Arnold, Nurse Educator, has used the facilities to support a renal dialysis student nurse, who was at TQEH for 10 weeks, and who then returned to Port Augusta for a further 10 weeks of training. Anne used the telemedicine link for tutorials and for discussing problems and evaluating the student's progress with training.

The two renal dialysis students from Port Augusta are starting their course in October 1995 and will use the telemedicine link to support their training. She believes it will offer improved continuity of learning to the students. The staff at Port Augusta feel quite isolated and are very responsive to using the link for staff development opportunities.

Anne can remain at TQEH in Woodville and conduct assessments of the staff at Wayville Dialysis Centre setting up a dialysis machine. She is keen to videotape live demonstrations which can be shown to distant sites by the videoconferencing system.

Educational use will increase when a training room is available in the new renal ward at TQEH. The nurse educators often have 10 students at TQEH and want to link to small numbers elsewhere, so a large room is needed. A multipoint bridge providing the connection of more than two sites will facilitate teaching.

She feels that "everyone is tuned into telemedicine" and she is "always thinking about the best way to use it."

Dr. Disney now regularly conducts a transplant clinic from his office by telemedicine to Port Augusta. The patients come into the Port Augusta satellite dialysis centre to discuss their health, laboratory results and treatment.

Registrar Dr. Toby Coates has become one of the most regular users of the telemedicine facilities. He is very aware of the advantages of telemedicine to the dialysis patients, who spend three sessions a week, each of four hours, on the dialysis machines. Scheduled sessions have been initiated each week during which he sees 2-3 patients, thus enabling them to avoid the necessity of travelling to TQEH to be seen in the outpatients department:

The major advantage is for the patients: if you have got to come in three times a week to be treated you don't want to spend one of those few other good days coming here to see the doctor, unless it is absolutely necessary.

Dr. Coates uses telemedicine for

• routine outpatient consultations
• troubleshooting in situations such as "when a patient has chest pain or a fall in blood pressure the nursing staff use the telemedicine facilities to allow me to assess the patient"
• examining patients while they are in the dialysis chair
• patient behaviour problems, as discussed below
• emergencies, which he has practical experience of, as noted below.

During the project, a male patient at Wayville refused to take direction from the clinical nurse, so the nurse used the telemedicine link to bring Dr. Coates into the discussion and he was able to convince the patient to take direction from the nurse.

An emergency arose in June 1995 while Dr. Coates was using the telemedicine link at TQEH Woodville to examine a patient at North Adelaide, and the patient fainted during the consultation. Dr. Coates was able to effectively manage the situation from Woodville, using the telemedicine link.

He is impressed with the image quality made possible by the main camera on the rollabout unit, which can zoom in to focus on regions of importance in the assessment of a patient's condition.

He is looking forward to using the desktop videoconferencing system in his office. He feels all the registrars are computer orientated and that they will respond well to the opportunity to use desktop videoconferencing. The telemedicine link enables him to keep in touch with activity at the other metropolitan centres, which he can only visit once per month.

He considers that telemedicine is enabling the staff to persuade patients to move from TQEH centre, with ready access to medical attention, to the satellite centres, where the telemedicine link can maintain regular contact with the medical staff.

Dr. Coates sees advantages in using the technology to follow up transplant patients who have moved from TQEH to the country. He is also keen to link to Darwin.

An electronic stethoscope capable of working over the telemedicine link is the next piece of technology that Dr. Coates would like to see added to the facilities.

"During a telemedicine consultation linking Dr. Alex Disney from his office at TQEH and the Port Augusta satellite centre, he noticed that the dialysis patient had an ulcer on her leg for which she would have to visit Adelaide to see a specialist. Dr. Disney contacted a surgical specialist to come to his office to look at the leg, by videoconferencing. The surgeon considered after looking at it that that an operation to have it removed could be scheduled at a later date, thus saving an outpatient visit to Adelaide." (Julie Meyer, Project Officer)

Helen Denman, Ward Clerk, plays a major role in scheduling telemedicine outpatient appointments to link patients at remote dialysis centres with their doctor at TQEH. She ensures that all the relevant patient data, such as the results of blood tests and x-rays, are available for the appointment. She also ensures that the telemedicine equipment is set up in the rooms at each site.

Helen rings the other sites at the start of each working day. She feels that:

People are not threatened by the system, they are comfortable with using it. It's now a regular part of the Unit's activities.

Helen feels that a major benefit of telemedicine is that patients at the satellite centres have only three rather than six visits per year to the hospital outpatients department, now that the link is used for every second appointment.

During a telemedicine consultation from his office at TQEH Woodville, linked to the Wayville Satellite Centre, Dr. Alex Disney was finding a long term dialysis patient resistant to a new course of drugs. Dr. Disney called into his room another long term patient who was happy with the new course of drugs and he left the two patients to discuss the issue. The Wayville patient, following this conversation, commenced the new drug regime.

Sharon Goldsworthy, TQEH pharmacist, uses the telemedicine facilities three times per week, for 30 minutes each time, to:

• liaise with the nursing staff at the satellite centres, particularly about drug supplies and patients prescriptions
• discuss drug usage with patients.

She is based at TQEH and, with a heavy schedule, is rarely able to visit the satellite centres, so the telemedicine facilities are crucial for her work.

Sharon sees enormous value in using the telemedicine facilities to assist new patients at the satellite centres to develop good habits regarding their drug intake. She believes that many of these patients develop non-compliance with their drug regime over 2-3 years, leading to their later admission for acute care. Telemedicine sessions have already helped patients develop good habits. A major benefit of the technology in the long term will be the reduction in the number of admissions of acute patients.

Sharon is becoming more adept at using the equipment:

I am learning more tricks. Initially it was difficult and I was not zooming in on the patients and I was missing the raised eyebrow. Now I place their big nose in the screen and can see all the facial expressions.

Initially I was yelling at the screen. Now as I use it more, I am developing new ways to approach patients.

Patient reaction has been very positive and often patients are excited and using the expression "my turn today." Only one patient initially refused to use telemedicine, but changed after having a chat with Sharon about his anxiety that he would "clam up" during the conversation.

Sharon is much more comfortable now that the patients can use the headsets for private discussion.

The document camera is used by her to draw illustrations for patients and she is learning to use it to display the patient's drug sheet. She is keen to use a multipoint facility, to reach more patients at several sites simultaneously for educational sessions.

"Using the telemedicine facilities, the staff at the satellite dialysis centres were shown the method of operating a new type of dialysis machine which they would use in the hospital unit." (Julie Meyer, Project Officer)

Sister Susan Brown, Clinical Nurse in charge at the Wayville satellite centre, uses the telemedicine facilities for nurse meetings between the centres, particularly with the Clinical Nurse Consultant. She feels that communication with the satellite centres has always been very poor, so she is talking to the nurse educators about providing some compulsory lectures.

She finds the technology to be exciting, but that the rollabout unit is too heavy for easy manoeuvring. She would prefer a laptop videoconferencing system. She considers the headsets used by the patients are excellent. Only one patient has flatly refused to use the telemedicine system, and a few find it difficult because they come from a non-English speaking background (NESB), or have hearing difficulties.

Sister Brown considers that the telemedicine system proved itself in the clinical setting when a patient had a seizure. She was able to call Dr. Disney with the videoconferencing system and work with him to assess the patient, and determine the appropriate treatment and transfer to the hospital. The alternative method of management would have been the use of ambulance transfer after some anxious moments without medical reassurance.

"The patients have got the choice, of course. They can spend three hours and come down to the hospital or they can spend an extra twenty minutes in the centre and then be done with it by telemedicine." (Julie Meyer, Project Officer)

Dietitian Fleurette Martin uses the telemedicine facilities on average once per week, but up to two or three times per week on occasion, to provide follow-up reviews with individual patients.

Fleurette talks to the patients while they're in their dialysis chairs during treatment. She notes that the patients invariably use the headsets for privacy.

Using the telemedicine facilities saves the time of both Fleurette and the patients: she does not have to travel to the satellite centres and the patients, who would see her when they attended the outpatients section at TQEH Woodville, have also saved time.

Patient responses have been very positive and a number have enjoyed using the keypad to control the camera. However, a number of patients not fluent in English have declined to use the system: the same patients referred to by Susan Brown, Clinical Nurse at Wayville.

Several important benefits of telemedicine identified by the dietitian are:

• patients now ask to see her via telemedicine, because they sense that the telemedicine facilities make her more accessible
• staff, realising that she is available, make patient appointments with her via telemedicine.

Aboriginal patients in Adelaide are able to communicate with their family at Port Augusta by using the telemedicine facilities. The renal liaison staff member is keen to use the system to help Aboriginal patients re-settle back in Port Augusta after being at TQEH Woodville

Cassie Shillabeer, Acting Clinical Nurse at the Port Augusta Satellite Centre, uses the telemedicine facilities for:

• calling on staff at TQEH, to advise on cannulations
• linking to technicians at TQEH regarding machine problems
• discussion of nurse management issues with Clinical Nurse Consultant Jayne Carpenter at TQEH
• assisting the Aboriginal Liaison Officer, Zosia Jary, link Aboriginal patients who need to move to Adelaide for treatment, with Aboriginal patients and family members at Port Augusta.

Cassie feels she has more support from TQEH staff, now that telemedicine is in place:

It's good not to be so alone here. It's helpful for them (TQEH staff) to be able to see what I'm doing. To have back up. It's more than a phone, they can see what I'm doing.

Cassie has helped organise some of the fitter patients to see Dr. Disney regularly on the telemedicine link, so that when he visits Port Augusta there is more time for the more seriously ill.

Jane-Marie Grantham, renal student at Port Augusta, used the telemedicine link to speak to the nurse educators at TQEH Woodville.

Cassie had used telemedicine in an urgent situation when a patient's fistula was clotting. Dr. Disney was able to manage the situation form TQEH Woodville and a trip by the patient to Adelaide was averted.

Patient reaction at Port Augusta has been only positive and the use of the headsets will now overcome the one problem, confidentiality.

The feedback from the above interviews revealed a range of uses and attitudes to use that were not detected by the extensive surveys conducted during the project. Possibly the most significant observations are:

• the high level of acceptance of the medium as part of the Unit
• the sense that staff have changed their work practices to take advantage of the technology and to improve their services to patients.
• Staff are also aware of the limitations of the equipment and have concrete suggestions about what can be done to improve it.
• In terms of cost effectiveness, the subject of chapter eight, many uses identified in this chapter have illustrated the variety of ways in which the technology has saved considerable expense.

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