Telemedicine and Remote Monitoring in Anesthesiology

Introduction:

Telemedicine is the most useful tool for people living in isolated and remote areas and is currently in practice in many medical fraternities. Telemedicine is a specialty that uses technology to support and provide health care across large distances.

What Is Telemedicine?

The term “telemedicine” was coined in 1970, which means” healing at a distance.” Telemedicine is defined by WHO (World Health Organization) as the delivery of healthcare services by healthcare professionals using information and communication technologies for exchanging valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities, where distance proves to be a critical factor.

What Are the Advantages of Telemedicine?

Providing healthcare services through telemedicine offers many advantages. It can make specialty care more accessible to underserved rural and urban populations through the following means:

• Video consultation with a specialist from a rural clinic will avoid unnecessary travel and associated costs for patients. It increases access to specialty consultations and/or second opinions for better diagnosis, treatment, and prognosis. One-to-one dialogue with a super-specialist expert and immediate guidance for the course of treatment in the case of an emergency can be taken up.

• Post-operative follow-up and rehabilitation support can be provided through telemedicine.

• Remote ICCU-CCU (Intensive care unit-cardiac care unit) can be monitored.

• Video conferencing comes up with options for continuing education or training the isolated rural health practitioners to take part in professional meetings or education programs, which might be otherwise not possible as they cannot leave the rural practice.

• The use of telemedicine can also cut the cost of medical care for those in rural areas.

What Does the Infrastructure of Telemedicine Consist of?

It comprises a minimum standard for all the hardware and software used in the telemedicine system.

1. Hardware: This includes the telemedicine platform, clinical devices, video-conferencing unit, and communication hardware.

2. Software: It consists of an operating system, licensed telemedicine software with an appropriate user interface (UI), and a back-end database with the mandatory tables or fields, if applicable.

3. Connectivity: option includes-

• VSAT (very small aperture telephone network).

• PSTN (public services telephone network).

• ISDN (integrated services digital network).

• Leased line.

• Wireless LAN/WAN (wireless local area network/wide area network).

What Is the Role of Video-Conferencing in Delivering Prompt Virtual Health Care?

• Video conferencing is becoming quite popular among hospitals. By using this technology, doctors can help patients who are unable to come to a hospital.

• Broadband has come as a big boost to telemedicine. With the availability of broadband, Video-conferencing ensures that the patients are treated irrespective of their financial condition, and this makes it popular in most countries.

• It is expected that home-based patient monitoring is also going to become popular, as well as remote surgery, which will involve surgery through robotics, with the surgeon in one location and the patient in another.

What Is the Role of Telemedicine in the Field of Anesthesiology?

• Telemedicine in the field of anesthesiology works on the concept of remote monitoring wherein the healthcare providers monitor the vital signs of the patients undergoing anesthetic care outside the traditional healthcare setting using digital medical devices and also will be able to monitor the anesthetic procedures through their expertise, carried out at remote areas.

• Telemedicine enables the delivery of healthcare irrespective of a geographic location or ability to travel to tertiary healthcare centers. In India, a significant population lives in remote regions away from tertiary care centers.

Telemedicine and remote monitoring in anesthetic care take place in the following steps which include:

1. Preoperative phase.

2. Intraoperative phase.

3. Postoperative phase.

Preoperative Phase

• The pre-anesthetic evaluation (PAE) includes consultation, which is done in the preoperative phase before any surgery, to review the medical history of the patient and to do the complete physical examination, including the systemic and airway examination.

• Pre-anesthetic checkups done through telemedicine are useful in terms of decreasing the need for patients to travel, benefiting those living far away from the clinic or those with physical disabilities, and it is cost-effective by decreasing the overall expenditure.

• For teleconsultation in the preoperative phase, explicit consent is required whenever the consult is initiated by a healthcare worker. This could be in the form of text, video, or audio messages, which have to be recorded and documented.

How Is Consultation Done in Telemedicine?

• A consultation set-up is made, which consists of a monitor, a camera, a desktop computer, and a digital stethoscope. When connected to the remote site, the anesthesiologist can visualize, hear, and auscultate the patient using the digital stethoscope system.

• The anesthesiologist inserts the digital stethoscope and earpieces in the same manner as a conventional stethoscope. An anesthesiologist is present at the consultant site, while an attending doctor or nurse can accompany the patient at the remote site during anesthesia consultation.

• The anesthesiologist takes a history from the patient as in a conventional consultation.

• Examination of the airway, respiratory, and cardiovascular system is performed. Mouth opening and the Mallampati score are assessed using the airway camera. The patient is then turned, and a side-view visual assessment of the airway profile, thyromental distance, and neck movement is made using the room camera.

• The nurse at the remote center is instructed on the positioning of the stethoscope on the patient’s chest and precordium. The rest of the consultation is conducted as per the conventional consultation.

• The relevant investigations ordered by the consultant anesthesiologist during the telemedicine consultation are noted by the attending doctor and are reviewed by the anesthesiologist on the day of surgery.

• General physical examinations, including the airway assessment and site for venous access, are also checked by the anesthesiologist on the day of surgery because the initial findings noted on telemedicine consultations may vary. So, a final review of history, physical examination, and investigations are important before giving anesthesia.

• A rapidly deployable telemedicine unit is utilized in remote anesthesia monitoring for assimilating and interpreting physiologic data such as electrocardiogram, SpO2, EtCO2, blood pressure, breath sounds, heart sounds, and video laryngoscopy.

2. Intraoperative Phase

• During the intraoperative phase, audio-video equipment, which is easily available in the operating room nowadays, can be used to transfer video cast between operating rooms, which helps in the visualization of anesthesia monitors and the operating room environment.

• Telemedicine can be of advantage in the intraoperative period in the form of providing remote guidance in remote environments and real-time surveillance of multiple operating rooms at the same point in time.

• It is imperative to have a proper relay of intra-operative parameters, and there should not be communication breakdown or technical issues leading to default in the transmission of vital parameters.

3. Postoperative Phase

• Telemedicine is useful even in the postoperative phase in the intensive care unit and post-anesthesia care unit by providing virtual surveillance.

• It helps clinicians in planning rehabilitation by recording postoperative milestones and carefully planning pain management, especially in daycare surgeries.

What Are the Limitations of Telemedicine and Remote Monitoring in Anesthetic Care?

• Telemedicine facilites are still in their infancy phase and are not available in many places.

• With the help of phone screening, one cannot do airway examination, heart and lung auscultation, or investigations such as ECG (electrocardiogram) and spirometry.

• Efficient use in remote locations with poor internet connectivity is questionable.

• Telemedicine usage in the preoperative phase in the pediatric age group would be difficult.

• Patient privacy is a matter of concern during teleconsultations. Results in the apprehension of the patient because of being examined from a remote location and inability to develop a rapport with the clinician.

• No standard operating protocol and guidelines have been developed for the usage of telemedicine in anesthesia.

Conclusion

With the ever-evolving technology, it is time to embark on a new journey in the field of anesthesia and utilize the services of telemedicine in anesthesia in the coming years. It will help the anesthesiologists to extend their spectrum of services not just within the hospital premises but also outside the hospital, leading to an overall improvement in the healthcare system.