Teleconsultation for Cardiac Patients: A Comparison Between Nurses and Physicians: The SHL Experience in Israel

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<ul><li><p>528</p><p>TELEMEDICINE AND e-HEALTHVolume 12, Number 5, 2006 Mary Ann Liebert, Inc.</p><p>Original Research</p><p>Teleconsultation for Cardiac Patients: A Comparison Between Nurses and Physicians: </p><p>The SHL Experience in Israel</p><p>ARIE ROTH, M.D.,1 ORI ROGOWSKI M.D.,2 YIGAL YANAY, B.A.,3MAYERA KEHATI, M.D.,3 NOMI MALOV, R.N.,3 and MICHAL GOLOVNER, M.D.3</p><p>ABSTRACT</p><p>The absence of randomized studies on sufficiently large patient cohorts precludes the draw-ing of any firm conclusions on the comparative performance between nurses and physiciansin transtelephonic triage and consultations and in diagnostic and management decision-mak-ing. We conducted such a comparative study at the SHL telemedicine facility. This facilityalso provides face-to-face medical management for its subscribers by means of mobile in-tensive care units (MICUs) staffed by physicians. The outcome of calls that came between7:00 AM and 11:00 PM throughout the study year and that were handled at random by speciallytrained physicians (n 15) or nurses (n 35) were analyzed. Of 48,707 subscribers who ful-filled the study entry criteria 25,106 used the service at least once, producing 88,103 calls (81,817handled by nurses and 6,286 by physicians). Teleconsultations were sufficient for most of thecases (80.13%). There were no significant differences between the performance of nurses andphysicians regarding demographics (age, gender) and medical diagnoses of the applicants.The nurses performance and decisions were comparable to those of physicians with respectto teleconsultations, medically justified dispatches of an MICU, repeated calls to the centerand mortality during the week after the index call, although the duration of the physicianstelephone consultations was longer. Delegation of equal authority to nurses and physiciansin triage and consultation in telecardiology results in equivalent and highly satisfactory med-ical care in a system in which subscribers receive service orchestrated from a single center oftelecommunications.</p><p>1Department of Cardiology, 2Department of Internal Medicine, Tel-Aviv Sourasky Medical Center, Sackler Facultyof Medicine, Tel-Aviv University, Tel-Aviv, Israel.</p><p>3SHL Medical Services, Tel-Aviv, Israel.</p><p>INTRODUCTION</p><p>ADVANCES IN TELECOMMUNICATION technolo-gies used in healthcare over the lastdecade have greatly expanded the possibilitiesof its application to a variety of services. In ad-dition to remote monitoring of vital signs,</p><p>home health agencies now provide diverse sys-tems for palliative care (hospice), rehabilita-tion, case management, chronic disease man-agement, virtual house calls, postsurgicalfollow-up, and more. People are living longerthan ever before in history, are better educatedand more comfortable with the use of these</p></li><li><p>new technologies. Most individuals want to re-main independent and live in their own homesfor as long as possible, even though more andmore members of our aging society suffer fromchronic conditions. While critical shortages ofpublic resources force healthcare providers todo more with less, consumer expectations forquality care and enhanced clinical outcomescontinue to rise unabatedly. It is, therefore, notsurprising that experts have recommendedgreater involvement of home health services inthe care of patients with chronic disease.14This recommendation is based on a number ofconsiderations, among which is the presump-tion that home healthcare nurses will reducehospitalization rates by educating patients, in-creasing patient compliance, detecting clinicaldeterioration and even decreasing costs tohealth providers.58</p><p>The concept of nurse practitioners is well de-veloped in the United States and has begun tospread to other Western countries as well. Inthe United Kingdom, for example, nurse prac-titioners are being increasingly used as the firstpoints of contact in primary care. Several au-thors have reported that physicians and nursesperform equally well in triaging patient visitsto their clinics,913 and that each group takenseparately is efficacious in performing trans-telephonic triage,14,15 and consultations16,17 aswell as in making diagnostic and managementdecisions.18,19 In-depth comparisons betweenthe performance of physicians and nurses,however, are few, and the ones that are avail-able involve small numbers of participants.Our search of the literature failed to elicit anyrandomized studies in sufficiently large patientcohorts to draw any firm conclusions.</p><p>SHL is a telemedicine system currentlyserving over 65,000 subscribers. As part ofSHLs ongoing self-assessment, we wanted toconfirm that our policy of equal delegation ofauthority to nurses and physicians in triageand consultation was in the best interests ofour patients. To that end, we conducted thisstudy to evaluate the decisions taken bynurses compared to those taken by physiciansin the same setting of this telemedicine sys-tem that employs a relatively large profes-sional staff to serve a very large patient pop-ulation.</p><p>MATERIALS AND METHODS</p><p>The system</p><p>The medical facility SHL, which incorporatestelecardiological and face-to-face professionalmedical assistance to its subscribers through-out Israel and the Jordanian West Bank terri-tories, has been in operation since 1987 and hasbeen described in detail elsewhere.2023 Briefly,SHL operates 24 hours per day, 365 days peryear through a monitoring center managed byspecially trained registered and/or intensivecare nurses who are authorized to dispatch mo-bile intensive care units (MICUs) staffed byphysicians and paramedics to subscribers liv-ing within a radius of 30 km of the cities of Tel-Aviv and Haifa. In the event that an SHL MICUis not available or when the call originates fromareas beyond SHLs MICU catchment area, anMICU from MDA (the Israeli Red Shield) or aregular MDA ambulance (i.e., without a physi-cian in attendance) is dispatched.</p><p>Subscribers (predominantly cardiac patients)as well as healthy individuals (Table 1) learnabout the system through advertisement andarrive independently or are referred by theirphysicians or other treating medical staff(home for the elderly, etc.).</p><p>Each subscribers complete medical file,which also includes a full 12-lead electrocar-diogram, is stored in a central computer and</p><p>TELECONSULTATION FOR CARDIAC PATIENTS 529</p><p>TABLE 1. DISTRIBUTION OF THE LEADING DIAGNOSES OFTHE 48,707 SHL SUBSCRIBERS INCLUDED IN THE STUDY</p><p>DURING JANUARYDECEMBER, 2003</p><p>Diagnosis (%)</p><p>Past myocardial infarction 24Anginal syndrome (any class) 23Dysrrhythmia (tachybrady arrhythmia 15</p><p>paroxysmal and/or chronic)Chronic conduction disturbances 15Poststatus any cardiac surgery 11Poststatus coronary angioplasty 10Congestive heart failure 8Postcardiopulmonary resuscitation 2Pacemaker/AICD 2Noncoronary heart disease 9Coronary risk factors only 28None of the abovea 27</p><p>aIncluding individuals who were ostensibly healthyand entirely symptom-free.</p><p>AICD, automatic implantable cardioverter defibrillator.</p></li><li><p>the records are continuously updated. All themembers carry a cardiobeeper by which theycan transmit a 3- (I, II, III) or 12-lead electrocar-diogram via a regular household or cellular tele-phone. Once a name or identification numberidentifies the caller, the appropriate medical fileis immediately displayed on a computer screenfrom which the nurse or physician retrieves allthe pertinent facts in addition to taking a real-time transtelephonic anamnesis. After interpret-ing the newly transmitted electrocardiographicdata, and based on the integration of writtenprotocols, computerized algorithms and her/hisclinical judgment, the nurse/physician may ei-ther dispatch an SHL MICU, an MDA MICU orambulance, or instruct the patient according tothe established medical or behavioral protocol.If it is the nurse who answers the call, he or shemay consult with the physician who is eitherpresent at the center or on-call. He or she is per-mitted to recommend over-the-counter medica-tions or those used regularly by the patient, butnot new drugs.</p><p>The staff is capable of handling calls in He-brew, Arabic (Israels second official language),Russian, and English.</p><p>Staff training</p><p>In order to be accepted as a staff member atSHL, both physicians and nurses must take awritten examination to evaluate their expertisein straightforward common cardiological is-sues, in the interpretation of case studies, in theidentification of life-threatening situations, andin the fields of electrocardiography and phar-macology (the latter with special emphasis oncardiovascular drugs). The candidates whomeet the stringent requirements are inter-viewed by two experienced senior physiciansin order to assess their suitability (in terms oftheir character) for working in this special set-ting. The ones who pass these tests are inter-viewed by the chief cardiologist, and specificgaps in their knowledge as revealed by earliertests are addressed. The candidates who arefound to need it undergo SHLs 160-hourcourse on executing and interpreting electro-cardiograms. The final stage of training in-volves 200 hours of hands-on experience in themonitor center under close supervision of a</p><p>personal instructor (an experienced nurse) and60 hours with the MICU team in the field. It isduring this period that the trainee becomeshighly familiar with all of the SHL protocolsand standing orders.</p><p>Continuing education and quality assurance</p><p>A staff meeting takes place every month forphysicians and every 3 months for nurses withthe purpose of analyzing and addressing newissues and orders, case studies and updates. Allcalls to and from the monitor center arerecorded, and at least 23 times per year threecalls are chosen at random for each staff mem-ber for analysis by the medical management (3physicians [including 1 cardiologist], 1 headnurse and 1 operational manager) who listento the calls and professionally assess the waythey were handled. The staff member is theninformed about the quality of his/her judg-ment and actions, and these remarks are addedto his/her personal file for comparison with thenext analysis.</p><p>Study period and patient population</p><p>After administrative and other miscella-neous calls had been screened out, all medicalcalls to the monitor center between January toDecember, 2003 were reviewed for this study.Only calls that came in between 7:00 AM and11:00 PM were included because those were thehours when physicians who triaged patientswere present at the monitor center.</p><p>DESIGN</p><p>Neither the nurses nor the physicians wereaware that their performances were being compared. The outcomes of all their telecon-sultations were assessed with respect to thesubscribers medical history that had been retrieved from their medical files. The endpoints for comparison and characterizationwere as follows.</p><p>Teleconsultations</p><p>These included all calls that were concludedon the telephone without any additional mea-</p><p>ROTH ET AL.530</p></li><li><p>sures, all calls which resulted in an additionalteleconsultation(s), and all calls that resulted inthe dispatch of an SHL MICU.</p><p>Justified dispatches of a MICU</p><p>All dispatches of a SHL MICU that resultedin the subscribers being transported to theemergency department of a hospital or in thenecessity for emergent or any medical treat-ment on the scene were considered as beingjustified. Of these, the ones in which the pa-tient needed to be taken to the hospital wereclassified as first order (Type A) justified calls,while the ones in which the dispatch concludedwith treatment of any kind at the scene (in-cluding as little as the administration of an oraltranquilizer) were considered as being secondorder (Type B) justified calls.</p><p>Unjustified dispatches of an MICU</p><p>All dispatches of an SHL MICU in which theexamining physician left the patient at homewithout any treatment or suggestion apartfrom the recommendation to call the centeragain in case of the reappearance or aggrava-tion of symptoms were considered as havingbeen unjustified.</p><p>Follow-up</p><p>Data on additional application(s) to the SHLmonitor center and on mortality during theweek after the index call to the center as wellas the result of dispatches handled by SHLsMICUs were retrieved. Because information onthe outcome of dispatches by other than SHLstaff members could not be completely docu-mented, only those dispatches treated by theSHL team were included in the final analysis.Mortality data could, however, be obtainedfrom relatives who called SHL to cancel thesubscription of deceased members.</p><p>Statistical analysis</p><p>Data were downloaded from the database ofsubscriber calls to the SHL center and trans-fered into the Statistical Package for the SocialSciences (SPSS, Chicago, IL) for analysis. Re-sults are given as mean standard deviation(SD) for continuous variables, such as staff</p><p>members working experience, and as numbersplus percentages for all dichotomous variables,such as gender, justified dispatches, etc. The 2analysis was used to compare the differentvariables between nurses and physicians. A pvalue 0.05 was considered statistically signif-icant in the analyses of the results.</p><p>RESULTS</p><p>General</p><p>During the study period, 48,707 subscribers ful-filled study entry criteria and their main cardiacdiagnoses are displayed in Table 1. There were26,799 (55%) males, and the age distribution ofthe cohort was 47% who were 6180 years of age;2%, 40 years or less; 25%, 4160 years; and 26%,81 years or older. During the study period 25,106subscribers (52%) called the center at least onceand 1 patient called 815 times. The breakdown ofthe frequency of calls is shown in Table 2.</p><p>The SHL medical staff that participated in thestudy consisted of 35 registered nurses withprofessional experience of 84 60 months(range, 6199 months) and 13 physicians withprofessional experience of 56 38 months(range, 18139 months).</p><p>Teleconsultations and triage</p><p>A total of 154,796 telephone calls consistingof teleconsultations or the dispatching of an</p><p>TELECONSULTATION FOR CARDIAC PATIENTS 531</p><p>TABLE 2. NUMBER OF CALLS PER SUBSCRIBERDURING THE ONE-YEAR STUDY PERIOD</p><p>No. of calls/year Subscribers (n 48,707)</p><p>0 23,601 (48%)1 9,8622 5,2523 3,0464 1,9045 1,274610 2,4381120 9322130 2033140 654150 615175 4776100 20101200 19201600 8815 1</p></li><li><p>MICU or ambulance were recorded through-out 24 hours per day during 2003, includingthose of subscribers without known or docu-mented cardiac disease. Of these, 94,169 callscame in between 7:00 AM and 11:00 PM and werehandled randomly by either nurses or physi-cians (whoever was available and picked upthe telephone).</p><p>All calls flagged with a standing order forphysician consultation only or for mandatorydispatch of an MICU (e.g., direct admission re-quested by the subscribers private physician)were excluded. This left a total of 88,103 callsof which 81,817 were handled by nurses (aver-age, 2,338 each) and 6,286 by physicians (aver-age, 484 each).</p><p>Telephone consultations lasted 6.88 6.98minutes for nurses and 8.97 6.88 minutes forphysicians (p 0.001). Those calls that endedwith an MICU dispatch tended to be a littlelonger for both nurses and physicians...</p></li></ul>


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