Running head: OUTLINE PROPOSAL: TELEMEDICINE USE WITH A REGIONAL 1

Outline Proposal: Telemedicine Use with a Regional Infectious Response Team

Tracy L Warren

Jacksonville State University

Research Methods

Dr. K. Prickett

July 2, 2017
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Outline Proposal: Telemedicine Use with a Regional Infectious Response Team

Introduction

In October of 2014, a virus that was briefly discussed in nursing school as something that

couldn’t happen in the United States suddenly became a household name. Preparedness efforts

across the country came to a halt, and the focus shifted to the threat of Ebola. Hospitals created

countless policies and procedures specific to the threat of Ebola, while staff attended mandatory

training on strict Personal Protective Equipment (PPE). “DHS expects all hospitals and

providers to prepare to identify, isolate, report, and safely manage patients suspected of having

Ebola until after consultation with DPH and EMS transport is arranged or an Ebola diagnosis is

confirmed by laboratory testing” (Wisconsin Department of Health Services, 2016, Preparedness

Tab).

Hospitals in the state of Wisconsin were asked to categorize, based on capabilities to

screen, test, and treat Ebola patients on three categories. The bulk of the hospitals categorized as

a level three facility, meaning they had an ability to “screen, identify, and isolate a patient with

risk factors” and then plans in place of where to transfer patients to for definitive care

(Wisconsin Department of Health Services Division of Public Health, 2016, para. 3). Category

two hospitals could provide care to a suspect Ebola case for up to 96 hours with support of

specially trained staff, available laboratory testing, transportation resources, specific care areas,

and enough supplies for a 96-hour timeframe (Wisconsin Department of Health Services

Division of Public Health, 2016). The State of Wisconsin designated four hospitals (two adult

and 2 pediatric) with attached medical schools as the category one hospitals, those able to

provide care for confirmed Ebola patients, located in Madison and Milwaukee, Wisconsin.
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By December of 2014, Wisconsin self-identified 20 category two hospitals across the

state, with one of those hospitals located within this writer’s health care coalition (State of

Wisconsin Department of Health Services, 2014). Regionally, the plan was to transfer suspect

cases to this hospital for additional testing and treatment. Throughout the state, sustainability for

these resources was lost over the next 6 months, leaving a gap in an assessment category two

hospital in this writer’s region.

The algorithm for local public health departments at that time was to monitor high risk

West African travelers for a 21-day period. If the patient became ill, the patient would be sent to

a local hospital for evaluation. Knowing that travelers can have a multitude of reasons for a

fever besides having Ebola, the regional health care coalition wanted to look at a better option

for the patient than sending them to an Emergency Department (ED) for evaluation. The health

care coalition discussed ways to be innovative; to help fill the needs not only for the potential

Ebola patient, but for the next emerging infectious disease threat as well.

This lead to a discussion on the use of telemedicine for the assessment and evaluation of

suspect cases. The idea would be to train a mobile team of critical care nurses, comprised of

volunteer staff from all four of the health care systems, to go to the patient, versus have the

patient present to a local Emergency Department (ED) upon signs of an illness within the 21-day

window of monitoring. With the use of telemedicine and computer-mediated communication

(CMC) devices, the patient would be evaluated by critical care nurses, paramedics, and/or

respiratory therapists, along with remote physicians able to view the assessment and treat

patients based on what they are observing. By developing a regional, collaborative approach, no

one hospital would be assuming a full workload, it would be shared by all four health care
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systems. This collaborative team would be the regional expert on strict PPE with the ability to

respond to not only Ebola, but the next emerging infectious threat as well.

Literature Review

The literature review consisted of searches related to prehospital use of telemedicine via

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and the

Assistant Secretary for Preparedness & Response (ASPR) Technical Resources, Assistance

Center, and Information Exchange (TRACIE). In 2015, the US Department of Health and

Human Services (HHS), ASPR developed a new online resource called TRACIE for healthcare

emergency preparedness (US Department of Health and Human Services, Office of the Assistant

Secretary for Preparedness & Response [HHS ASPR], 2015).

Telemedicine use has become increasing popular over the last few decades, helping to

connect medical specialties to patients remotely via computer-mediated communications (CMC)

in various specialties such as stroke, trauma, and cardiac care (Amadi-Obi, Gilligan, &

O’Donnell, 2014). The question remains on how to effectively expand telemedicine for use in

emergency preparedness and public health. There are significant areas of research opportunity

for the use of CMC in conducting high-risk infectious remote consultations in the field versus

having high risk patients present to local hospitals.

At the National Center for Research Resources Conference in 2010, an expert panel

discussed telehealth tools and use for public health, emergency, and disaster preparedness and

response. This panel noted that there were identified gaps that could benefit from further

research and development as it relates to patient outcomes, cost effectiveness, sustainability, and

the development of a best practice model for use (Alverson et al., 2010). This theme was

echoed in a review of telemedicine applications in the pre-hospital environment published in the

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International Journal of Emergency Medicine in 2014, as prehospital telehealth services are

expanding and have the potential to improve patient outcomes and increase cost effectiveness

(Amadi-Obi et al., 2014).

A 2014 article in Critical Care magazine discussed the use of a telemedicine application

that was utilized post disaster in Brazil following a nightclub fire. In this scenario, a mobile

telemedicine device was installed in the main hospital receiving patients (Piza, Steinman,

Baldisserotto, Morbeck, & Silva, 2014). This enabled the emergency room staff to connect with

specialists remotely in order to provide medical guidance for care, assisting with diagnoses, and

requesting additional supplies (Piza et al., 2014). Based on their experience with telemedicine,

felt there was an application and role for telemedicine in disaster or emergency situations with

limitations of infrastructure (Piza et al., 2014).

In 2008, a Danish group of researchers conducted what they called the “world’s largest

telemedicine project” in order to fill in gaps from other studies in relation to cost effectiveness

and improved patient outcomes (Kidholm, Dinesen, Dyrvig, Schnack Rasmussen, &

Yderstraede, 2014). Their trial however, was focused on patients with chronic diseases not

emergent evaluation.

The literature continued to yearn for more answers and research on the use of

telemedicine as a mobile tool linking patient care in the field to remote providers. The current

proposal is focused on meeting an immediate gap surrounding Ebola, however this team would

be a support response to any emerging highly infectious disease and other situations such

decontamination. The research question is: Could telemedicine be used within a mobile team of

health care professionals to accurately screen, evaluate, and refer high risk infectious disease

patients? The additional level of complexity to this project is the use of strict PPE.
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Conceptual Framework

As the field of telemedicine grows there becomes a need to help better understand the

multifaceted juncture of combining the nurses’ role, nursing care, clinical knowledge and

decision making, and incorporating the scientific telemedicine by creating a conceptual model.

In 2014, Daniel Nagel and Jamie Penner wanted to evaluate what models were currently being

utilized and how that fit with how telemedicine has evolved over the past decade (Nagel &

Penner, 2015). Upon the review of literature, it was discovered most conceptual models or

framework were geared towards the use of telephone based services and unable to correlate to

the current use of telemedicine services. Any conceptual model that was currently being used

needed further development and expansion to explain this new quandary on patient centered care

using technology.

Nagel and Penner used the components for their reviews as a foundation, creating a

conceptual model to begin the discussion and visualize achieve patient centered care in this new

technological era. In their model, they describe four main keys that help frame patient care

utilizing their model- knowing the person, building a picture, clinical decision making, and

nursing competencies (Nagel & Penner, 2015). The researchers felt that these four components

were essential to ensuring patients received the best care. In the model, each component

overlaps the other indicating the intricacy and interrelatedness of the concept.
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Fig. 1 Conceptual Model of Telehealth Nursing (Nagel & Penner, 2015, p. 102)

The model presented by Nagel and Penner is applicapable to this research proposal.

Method

The method for this research proposal will be a holistic and intrinsic case study in the

development and implementation of a regional mobile team of health care providers utilizing

telemedicine to screen, evaluate, and refer high risk infectious disease patients and develop best

practice guidelines. The holistic and intrinsic design component will examine how this mobile

team will collaborate between separate health care systems and work within the community to

fill the gap in regional services.

This mobile team would be a benefit to the individual health care organizations. There

are 4 different health care systems in the region. Each hospital has been asked to request staff

that would be interested in joining this new initiative. Oversight would fall under the Fox Valley

Health Care Coalition with supplies, equipment, and training paid for by the health care coalition

and grant funding. Each hospital would assume the cost of their staff’s respective training time

as well as covering the individual caregivers’ liability. It is the researcher’s belief that by
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collaborating in this innovative manner, it will help relieve the financial and labor-intensive

burden if each entity were to have teams of specially trained staff at each entity. Fiscal

responsibility can be evaluated using a comparative cost analysis on labor, equipment, training,

and supplies for the mobile team versus the calculation for each individual hospital.

Regional collaboration is mandated by hospital accreditation bodies such as the Joint

Commission (TJC) as well as the Centers for Medicare and Medicaid Services (CMS). The

recent CMS Emergency Preparedness rule update released in fall of 2016, effective November of

2017, added significant requirements for hospitals (and other entities accepting CMS

reimbursement) regarding preparedness initiatives such as health care coalition involvement and

ensuring staff has adequate training for all hazards (U.S. Centers for Medicare & Medicaid

Services [CMS], 2017). This research proposal helps to meet this requirement through

collaboration, but also utilizing the resources available to ensure community and regional

preparedness.

This case study will be conducted over the next 12-14 months under the umbrella of the

Fox Valley Regional Health Care Coalition (HCC) with support of the coalition’s medical

director and regional hospitals under this writer’s lead. As discussed earlier, staff from the

participating regional hospitals will engage in hands on training, education, the use of strict PPE,

as well as telemedicine tools to help evaluate patients in their home. Basic process outlines have

been developed and are being worked through. These processes will be collaboratively reviewed

with the team. During this period, trainings will be held at Fox Valley Technical College Public

Safety Training Center. Training will consist of classroom practice time and scenario based

training in the simulation city on campus with residential buildings. By training in this

environment, the team will be able to test strategies for donning and doffing PPE in the field as
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well as telemedicine evaluation. The process models will be reviewed for effectiveness as well

as for points of failure. The team will be able to help develop best practice guidelines based on

trial and error, with a potential pilot study in a mock environment.

Results

It is important that the results of this research project present a proposal for best practice

guidelines, transferrable to other health care coalitions or entities looking to implement a similar

approach to emerging infections with a mobile team of health care providers with the aid of

telemedicine technology. It is this researcher’s intention that the lessons and information

rendered via this case study is successful and sustainable. The results presented will identify a

cost analysis of the program as well as opportunities for further research development.
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References

Alverson, D., Edison, K., Flournoy, L., Korte, B., Magruder, C., & Miller, C. (2010,

January/February). Telehealth tools for public health, emergency, or disaster

preparedness and response: A summary report. Telemedicine and e-Health, 112-114.

http://dx.doi.org/10.1089/tmj.2009.0149

Amadi-Obi, A., Gilligan, P., & O’Donnell, C. (2014, July 5). Telemedicine in pre-hospital care:

A review of telemedicine application in the prehospital environment. International

Journal of Emergency Medicine, 7. http://dx.doi.org/10.1186/s12245-014-0029-0

Kidholm, K., Dinesen, B., Dyrvig, A., Schnack Rasmussen, B., & Yderstraede, K. (2014).

Results from the world’s largest telemedicine project: The whole system demonstrator.

European Wound Management Association Journal, 14(1), 43-48. Retrieved from

http://ewma.org/fileadmin/user_upload/EWMA.org/EWMA_journal_archive/Journal_1_

2014_5_final_WEB.pdf

Nagel, D., & Penner, J. (2015, March). Conceptualizing telehealth in nursing practice. Journal of

Holistic Nursing, 34, 91-104. http://dx.doi.org/10.1177/0898010115580236

Piza, F., Steinman, M., Baldisserotto, S., Morbeck, R., & Silva, E. (2014, November 27). Is there

a role for telemedicine in disaster medicine. Critical Care, 18.

http://dx.doi.org/10.1186/s13054-014-0646-2

Polit, D. F., & Tatano Beck, C. (2017). Nursing research: Generating and assessing evidence for

nursing practice (10th ed.). Philadelphia: Wolters Kluwer.

State of Wisconsin Department of Health Services. (2014). Ebola situation report. Retrieved

from https://www.dhs.wisconsin.gov/disease/sitrep-12-11-14.pdf
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US Centers for Medicare & Medicaid Services. (2017). Emergency Preparedness Rule. Retrieved

June 29, 2017, from https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

US Department of Health and Human Services, Office of the Assistant Secretary for

Preparedness & Response. (2015). Welcome to ASPR TRACIE. Retrieved June 25, 2017,

from https://asprtracie.hhs.gov/

Wisconsin Department of Health Services. (2016). Ebola virus disease partner information:

Ebola information for healthcare professionals and other partners. Retrieved June 24,

2017, from https://www.dhs.wisconsin.gov/disease/ebola-virus-disease-partnerinfo.htm

Wisconsin Department of Health Services Division of Public Health. (2016). Ebola hospital

categorization. Retrieved June 24, 2017, from

https://www.dhs.wisconsin.gov/disease/hospitalcategorization.pdf