Original ArticleTelemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients
Introduction
Severe traumatic brain injury (TBI) represents the leading cause of death and long-term disability, with substantial public health implications worldwide.1, 2, 3, 4, 5, 6 TBI is most commonly associated with road traffic injuries, falls, violence, and injuries related to occupations or sports. Moreover, most low- and middle-income countries lack adequate numbers of neurosurgeons, institutions, or trauma centers to optimally care for TBI patients; thus TBI patients have the worst outcomes in these countries.5 TBI patients are often transferred from remote sites to tertiary centers at enormous financial cost to the patient, family, and health care system. These delays are often detrimental in providing adequate resuscitation and definitive care in a timely fashion, which affect the final outcomes. However, long and costly transfers may ultimately prove to be unnecessary, dramatically decreasing the associated health care expenses.
In recent years, telemedicine allowed trauma centers to manage patients from a distance, assisting in prehospital assessment, interventions, and definitive hospital care, as well as supporting disaster and emergency management.7, 8, 9 Despite a number of successful applications of telemedicine for stroke and other emergencies,10, 11, 12 data for neurotrauma management are scarce. Only recently has telemedicine for neurosurgery gained its deserved attention.13
Most patients with head injuries may not need operative treatment and can be managed by local nontrauma and non-neurosurgical expertise hospitals. Those with severe brain injury (Glasgow Coma Scale [GCS] <12) obviously will require neurosurgery attention, but even in those patients not everyone requires a surgical intervention. While telemedicine has been implemented for trauma and emergency care in several countries, teleneurotrauma, particularly in the developing world, where there is lack of neurosurgeons and neurosurgery expertise, may have significant importance. More commonly, a country may have a single tertiary hospital with neurosurgery expertise; however, transport to the main center from remote sites of the country is often difficult, if not impossible. It has been reported that there are 23,940 neurosurgeons in a world with a population of almost 6 billion people, making the ratio 1 neurosurgeon: 230,000 people. Moreover, 60% of neurosurgeons manage only 14% of the world population, whereas only 6% of neurosurgeons take care of 34% of the world of population in low- and middle-income countries.14
Albania, a southeastern European middle-income country, has a health care system that has been struggling to provide adequate access and quality of care, particularly in trauma and emergency care despite its political stability.15, 16 The most recent analysis of Albania's trauma system using American College of Surgeons/Committee On Trauma criteria found that trauma and emergency medicine systems are in need of major reforms involving all essential elements in order to meet the basic requirements of a structured trauma system.14 Moreover, the emergency services in Albania are currently staffed with inadequately trained personnel, who lack equipment and protocols. In a recent study of 42 public hospitals,16 we found that less than half of physicians and one third of nurses (7.1%–26.0%) working in emergency departments received specialized trauma training. About half (47.9%–57.1%) of the emergency department physicians and one fifth of the nurses (18.3%–22.9%) possessed basic life support certification. This study demonstrated some significant differences in the emergency medical care provided among primary, secondary, and tertiary hospitals across Albania. Specifically, these differences involved spinal immobilization (P = 0.01), Focused Abdominal Scan for Trauma (P = 0.04), splinting (P = 0.01), closed reduction of displaced fractures (P = 0.02), and nurses performing cardiopulmonary resuscitation (P = 0.01). Between 50% and 71.4% of the facilities showed a combined lack of training and supplies as the reason for not offering interventions such as rapid sequence induction, needle thoracotomy, chest tube insertion, and thrombolytic therapy.
Our group has been working in Albania to establish a robust integrated telemedicine system17, 18, 19 (Figure 1). One of the main pillars of the Albania program is that telemedicine for neurotrauma provides care for all neurotrauma for the entire country. The aim of present study is to describe the initial results, experience, and outcomes of consultations provided via telemedicine in series of neurotrauma patients. This study has been reported in line with the PROCESS guidelines.20
Section snippets
Materials and Methods
A case series study was conducted from prospectively collected data on all telemedicine consultations for isolated neurotrauma performed by the Department of Neurosurgery of the National Trauma Center of Tirana, the capital city of Albania, and regional hospitals across the country between January 2014 and December 2016.
Patient demographics, associated diagnostic testing, mechanism of injury, whether the patient was transferred or was maintained for further observation in the referring
Results
A total of 146 telemedicine consultations for isolated neurotrauma (brain and spinal cord injuries) occurred during the study period. Patients were referred from 7 regional hospitals (Figure 2). The median day for teleconsultations post injury was 0 (i.e., same day) (range 0–12 days). The response from the consulting hospital was obtained in median time of 20 minutes (range 1 minute to 12 hours). Asynchronous technology (store-and-forward) accounted for the majority of the teleconsultations
Discussion
This study reports a successful application of telemedicine for neurotrauma. To our knowledge, this is one of the first studies to describe a national telemedicine program that has developed a unique teleneurotrauma on call 24/7 for the entire country, using an integrated national telemedicine network, and demonstrates that telemedicine for neurotrauma when structured appropriately and with the participation of all neurosurgeons of the department (including neurosurgery residents) is extremely
Limitations of Study
The study had a number of weaknesses. Although all patients were placed on the database prospectively, the quality of data collected was less than optimal, as there was no trauma registry or electronic health record and there is no culture of data collection. Although we do not have outcome data on patients who remained at the referring hospital, no patients were subsequently transferred to the National Trauma Center. Furthermore, we have not yet analyzed the cost-savings of telemedicine
Conclusions
Telemedicine for TBI, when structured appropriately and with active participation of neurosurgeons, is extremely valuable service for the entire country.
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2021, World NeurosurgeryCitation Excerpt :Telemedicine has been practiced for quite a long time and has been commonly used in developed countries to provide health care to populations in remote or poorly accessible areas.1,2 Though the earliest published reports on the use of telemedicine in neurosurgery date back to the late 1990s, the need of telemedicine has never been felt more acutely than during the coronavirus disease 2019 (COVID-19) pandemic.3-11 A dramatic increase has been seen in the amount of literature on telemedicine in 2020, reflecting a growing popularity and adoption of this mode of seeking medical advice.
Telemedicine for Neurotrauma Prevents Unnecessary Transfers: An Update from a Nationwide Program in Albania and Analysis of 590 Patients
2019, World NeurosurgeryCitation Excerpt :Even among patients with severe TBI (Glasgow Coma Scale score <12), not every patient requires surgical intervention. In our previous report of 34% of 146 patients transferred to the National Trauma Center, only 9% were treated operatively.20 Other investigators have also demonstrated that many patients with mild head injuries can be managed by nonneurosurgeons as long as neurosurgery services are available on a timely basis and if the patients are monitored closely by the trauma team.23
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Conflict of interest statement: The study is part of the project funded from the United States Agency for International Development in Albania, Integrated Telemedicine and e-Health Project (Contract 182-A-00-09-00101-00).