Literature Review: The Role Of Telemedicine In Traumatic Brain Injury

Introduction

The human brain is the center of physical, social, and cognitive existence.  This infinitely complex organ is responsible for regulating and monitoring the human body’s actions and reactions as it is the core of the central nervous system.  It continuously receives sensory information and analyzes data responding with phenomenal control of bodily functions and physical actions.  It is imperative that the brain is highly respected as it is critical to life and delicate in nature. 

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As a result of this delicacy, the brain is highly susceptible to insurmountable forms of damage.  A causative factor of this acquired harm may include traumatic brain injury.  Traumatic brain injury (TBI) involves a spectrum of destructive insults to the brain which can result in devastating outcomes and lifelong physical, cognitive, and psychosocial impairments.  Attributing causes may include falls, sports related injuries, physical force, explosions, concussive blasts, and motor vehicle accidents. 

TBI is the leading cause of death and disability in the United States among civilian and military persons.  As a result of current wars, there has been a dramatic increase in the use of improvised explosive devices (IED’s) by enemy forces for warfare and terrorism.  In turn, the use of IED’s has been a causative factor for combat inflicted traumatic brain injury.  Consequently, TBI has become the signature injury of American forces fighting wars overseas and has been labeled the “silent epidemic” (Doarn, McVeigh, & Poropatich, 2010).  In order to minimize lasting impacts on soldiers that are valiantly serving, technological breakthroughs in the area of telemedicine must be utilized for early detection, evaluation, and treatment of traumatic brain injury.  The purpose of this paper is to investigate the role of telemedicine and the remote clinical nursing management of combat related traumatic brain injury.

Description of the Clinical Problem Being Addressed

Traumatic brain injury is a serious health concern that can have lasting effects on an individual’s quality of life.  In hostile combat environments, a diagnosis of TBI can be accidentally missed resulting in delayed or absence of care.  In previous conflicts, survivability of such devastating brain injuries was far less due to limited time and resources available at front line medical commands.  With the evolution of modern medicine and technological advances in trauma care, a wounded warriors chance of survival has significantly improved.  An example of this advanced technology is referred to as telemedicine, which enables health care professionals to provide distant medical consultation and treatment in remote locations.  The role of this technology is crucial within the Department of Veterans Affairs (VA) and the Veterans Health Administration (VHA) by enabling the monitoring and care of military personnel isolated by geographic location, destitution, and disabling conditions. 

Proposed Informatics Solution

In combat environments, rapid identification and treatment of traumatic brain injury is a critical component aimed towards reducing lasting impacts of the neurologic insult on wounded soldiers.  The use of telemedicine by the United States military has proven beneficial in the identification of injury, initiation of treatment, follow up coordination, and support for recovery.  Revolutionary advances in the domains of telemedicine, tele-consultation, and tele-rehabilitation has transformed the way clinical professionals provide medical care, nursing care and education to service members inflicted with mild to severe TBI.  “Interactive video-teleconferencing (VTC) and Web-based store and forward technology are bridging the gap between doctors, nurses and patients separated by hostile combat environments” (Girard, 2007).  The utilization of telemedicine by the armed forces facilitates improved patient access to specialized medical services.  As a result, critically wounded soldiers receive improved quality of care and avoid unnecessary medical evacuations that may consequently diminish military unit readiness.

As a result of current global conflicts and geographical isolation, there has been a dramatic increase in combat related casualties from traumatic brain injury.  Recognizing the need for improved identification of TBI and development of a solution for this intractable loss, the military has launched an initiative targeting the demand for telemedicine.  This invaluable technology “can extend such clinical activities as neurological assessment, acute medical and neurosurgical treatment, psychiatric intervention, behavioral therapies, nursing consultation, occupational and physical rehabilitation and overall service coordination between military, VA and community programs“ (Girard, 2007).  The United States Army’s Telemedicine and Advanced Technology Research Center (TATRC) has initiated multiple innovative approaches utilizing basic technology to quickly identify and manage combat related head injuries.  “It has developed several telemedicine-based research initiatives for the treatment of TBI, including the application of cell phone (mCare) technology for communications and monitoring, and the use of the transcranial doppler for severe TBI patients” (Doarn, McVeigh, & Poropatich, 2010).  In order to manage the spectrum of associated devastating outcomes from TBI, the collaborative effort of numerous disciplines and specialty services is imperative.  To integrate these highly specialized subgroups, various forms of telemedicine may benefit patients who sustain brain injuries over the course of their care.  Bridging the gap between crucial healthcare sectors will greatly improve the continuum of care for service members surviving TBI.

Implementation of the Solution

Hostile war zones and associated explosions contribute to an increase in documented cases of head injuries.  Clinicians are under increased pressure to quickly identify TBI to potentially minimize casualties and negative outcomes.  Researchers at the Defense and Veterans Brain Injury Center (DVBIC) have addressed the need for improved identification of TBI.  The research team collectively “tested a remote cognitive assessment system that may allow clinicians and nurses in the field to more rapidly gather information on reaction time, memory, and mood” (Girard, 2007).  With the addition of comprehensive medical information, the patient’s neurological assessment may produce more realistic results of cognitive and emotional functioning.  TBI specialists can analyze the assessment findings at distant locations utilizing secure Web based systems.  Following comprehensive analysis, recommendations from the TBI specialists to the attending health care team on treatment strategies, can improve survival rates and decrease long term physical and psychosocial deficits.

Current innovations in telehealth technology have enabled combat nurses to utilize handheld devices for screening and assessment of wounded service members.  Future development of testing tools and algorithms could be integrated with the current hand held devices to expedite the screening process and update the patient’s medical records with current TBI symptom findings.  “Vital medical history data is already in existence in the electronic dog tags of special operations forces.  The Army’s Battlefield Medical Information System for Telemedicine is a handheld device that communicates with these dog tags and allows medical personnel to store, retrieve, and transmit data at the point of care” (Girard, 2007).

With future use of hand held devices, additional testing tools including the TBI guidance and neurocognitive test batteries may be implemented to assist clinicians to treat TBI inflicted soldiers.  The Telemedicine and Advanced Technology Research Center is collaboratively working with the DVBIC to combine the proposed systems into existing hand held devices.  A model system would provide optimal data access without threatening sensitivity, validity, or reliability of the tested cognitive domain measures that are generally compromised after a TBI.

Review of the Evidence:

This literature review includes five relevant peer-reviewed studies focusing on telemedicine, traumatic brain injuries, and the military. Sources included CINAHL and Google Scholar databases using the following search terms: “telemedicine,” “traumatic brain injury,” “active duty military,” and “veterans.” The time frame was set between 2000 and 2017.  The search produced one quantitative study, two mixed studies, and two qualitative studies.  The sample sizes ranged from 1 to 639.

Yurkiewicz, Lappan, Neely, Hesselbrock, Girard, and Alphonso (2012) conducted a quantitative study evaluating the usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program for neurology and traumatic brain injury (TBI) cases in remote combat zones overseas with limited access to resources and subspecialists. The study includes a descriptive analysis of the active number of consults, response times, original location of consults, military branches involved that benefitted, anatomic locations of injuries/problem areas, and diagnoses.The design of the study was a retrospective analysis that searched online electronic databases for neurology consults dating from October 2006 to December 2010 and TBI consults dating from March 2008 to December 2010. During these timeframes,508 consults involved neurology complications and 131 consults involved TBI’s sustained in active combat zones. It was discovered that as the quantity of consults increased over the years, response times decreased with a mean response time of 8 hours, 14 minutes for neurology consults and 2 hours, 44 minutes for TBI consults. In regards to the location of consults, 67.59% of neurology consults originated in Iraq followed by 16.84% in Afghanistan, meanwhile 40.87% of TBI consults originated in Afghanistan followed by 33.91% in Iraq. While 52.1% of neurology consults had the medical diagnoses of migraine headaches, 52.3% of TBI consults were diagnosed with mild TBI/concussion. As a result, subspecialists acting as consultants recommended on-site management which resulted in the facilitation of 84 known neurology evacuations, and the prevention of 3 known neurology evacuations. After analyzing the results of this study, researchers were able to determine that “TBI subspecialty teleconsultation is a viable method for overseas providers in distant locations to receive expert recommendations for a range of neurologic conditions.  These recommendations can facilitate medically necessary patient evacuations or prevent evacuations for which on-site care is preferable” (Yurkiewicz, et al., 2012).

Turkstra, Quinn-Padron, Johnson, Workinger, and Antoniotti (2012) conducted a mixed study with the purpose of comparing in-person (IP) to telehealth (TH) methods to assess discourse ability in adults with chronic traumatic brain injury (TBI). The design used was a repeated-measures design with random order of conditions and included a sample of twenty adults with moderate-to-severe TBI. Participants in the study were recorded and transcribed while completing conversations, picture descriptions, story-generations, and procedural description tasks in order to measure the productivity and quality of discourse. According to the researchers, “there was no statistically significant difference in RBANS scores that was detected between the two conditions, F (3,1) = .09, p = .77, no statistically significant difference was detected between telehealth and in-person discourse performance on measures of language productivity, variety, or fluency or clinician behavior” (Turkstra et al., 2012). As a result, these preliminary findings support the use of TH for the assessment of discourse ability in adults with TBI, at least for individuals with sufficient cognitive skills to follow TH procedures.

Considerable numbers of U.S. military veterans who served in recent conflicts have experienced mild traumatic brain injuries. It has been proven that as many as 25% of veterans do not have a comprehensive traumatic brain injury evaluation following a catastrophic event. Technological advancements such as clinical video telehealth offer a potential means to overcome potential barriers that can prevent a veteran from receiving a comprehensive traumatic brain injury evaluation following a positive screening. Martinez, Hogan, Lones, Balbale, Scholten, Bidelspach, Musson, and Smith (2017) conducted a qualitative study to explore the perspectives of health care providers associated with the Veterans Health Administration on implementing clinical video telehealth technology for the assessment and treatment of mild traumatic brain injury among veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. This study took place at the Veterans Health Administration Polytrauma System of Care and included twenty-six providers who participated in a Veterans Health Administration Rehabilitation and Prosthetic Services Teleconsultation Pilot Project for administering comprehensive traumatic brain injury evaluations over clinical video telehealth. Data was collected through semi-structured interviews that used content-analytic techniques to assess provider experiences implementing clinical video telehealth for veterans with traumatic brain injury. As a result of the study, it was discovered that the most commonly reported inhibiting factors to implementing clinical video telehealth for traumatic brain injury evaluation and treatment included scheduling, setting up the clinic, and conducting physical examinations over a virtual modality. To enhance clinical video telehealth implementation, participants described best practices including establishing effective communication techniques and relationships with staff, building rapport with patients, and recognizing the unique needs of patients with traumatic brain injuries. The implementation of clinical video telehealth programs requires the coordination of multiple steps with providers at different sites, which further stresses the need for effective communication. Provider-patient communication also emerged as vital to successful clinical video telehealth implementation in order to ensure the patient is receiving the highest quality of care possible. These findings suggest that providers would ultimately benefit from efforts to build communication competencies and eliminate potential barriers to care.

Schoenberg, Ruwe, Dawson, McDonald, Houston, and Forducey (2008) conducted a mixed study that compared outcomes of 19 participants who received computer-based cognitive teletherapy rehabilitation with 20 participants who received face-to-face speech–language rehabilitation. The study analyzed outcomes from 2 “real-word” treatment programs provided by an outpatient rehabilitation center and included a total of 39 participants with moderate to severe closed head TBI’s. Outcomes were measured based on significant clinical indicators of independent living status, return to work or school, and independent driving, and cost. Cost measures comprised of the total cost of the treatment and a measure of service costs per hour. According to the researchers, “time since injury was a covariate, and an analysis of covariance revealed no differences between groups in independent living, driving status, return to work or school, or total treatment costs” (Shoenberg et al., (2008). The results of the study yielded that the computer-based teletherapy cognitive rehabilitation program provided similar functional outcomes as face-to-face speech–language therapy at a similar total cost, making it a desirable option for future care.

Advancements in the design and delivery of acute trauma care and management has ultimately increased the outcomes and number of survivors from traumatic brain injury (TBI). Although access to health care for rural patients remains a constant challenge, teletherapy represents a viable means for the advanced delivery of therapeutic services to high-risk patients with limited access to healthcare and its resources. In addition to their mixed study comparing cognitive teletherapy to face-to-face speech language rehabilitation, Forducey, Ruwe, Dawson, Scheideman-Miller, McDonald, and Hantla (2003) conducted a qualitative study with a case study design in which teletherapy was successfully utilized to improve the physical as well as cognitive functional outcomes of a patient with a severe TBI. The study involves a physical therapist based in a metropolitan rehabilitation center, that utilized the advancing method of teletherapy to provide neuro-developmental treatment to a patient in a nursing home located over 100 miles away. The patient participated in 48 physical teletherapy sessions over a 24-week period, and demonstrated improvements in physical functioning and neuropsychological status by the end of the treatment period. During the course of therapy, patient goals were constantly adjusted upward to match and drive the patient’s improvements. This case study provides complementary evidence supporting the theory that “teletherapy represents an effective and efficient means for providing rehabilitation services for patients in rural communities, as well as for facilitating mentoring relationships between seasoned professionals and trainees located in rural settings” (Forducey et al., 2003). 

Barriers to Overcome

At this time, there are not any instruments in existence that would facilitate delivery of data utilizing telehealth technology in war zones without requiring some form of sacrifice due to the assessment environment, computing limitations such as reliability of connection, adequate processing power and resolution of the camera.  With widespread use of this technology, financial and bureaucratic barriers exist with initial start up fees, equipment purchasing, sustainability and training of clinicians, nurses and allied health staff. In addition, it must be considered that despite the fascinating advancements in medical technology, the human connection between the clinical professionals and the injured soldier is the most critical element of all remote telemedicine interactions.  Furthermore, in isolated geographical regions, “an unskilled telemedicine operator is no more capable of treating the patient from a distance than is a similarly untrained live physician on-site” (Telemedicine in 2010: Robotic Caveats, 2010).  Under the direction of qualified neurologists however, teleneurology can be a successful extension of on-site clinical specialization.

Success Evaluation of Proposed Solution

The Veterans Health Administration recommends additional research in the area of telehealth technology and supports current system approaches including video consultation and store-and-forward technologies.  These current systems may provide the means for TBI specialists to conduct distance assessment on patients while additional measures for testing are validated.  In mobile army surgical hospitals, clinicians and nurses can consult live with specialists in the United States utilizing interactive video teleconferencing.  “The Army Hospital in Bagram, Afghanistan, for example uses its VTC system in the operating room for teleneurosurgical mentoring.  This system allows general surgeons operating on the patient in theater to consult with specialists at Walter Reed Army Medical Center (WRAMC) (Washington DC), who are linked into the operation via VTC” (Girard, 2007).  The use of live interactive VTC is a valuable resource for enhancing coordination of care between mobile military medical units and TBI specialists in the United States.  Researchers predict that these interactive and innovative approaches are projected to improve the response capability of the military and Veterans administration to TBI management in the near future.

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The United States Department of Defense (DOD) utilizes telecommunication media to address critical issues focusing on combat related trauma, patient evacuation, and air transport procedures.  The DOD and Veterans administration Trauma Continuum of Care conducts monthly meetings with mobile emergency and surgical staff and clinicians worldwide using video teleconferencing technology.  Implementing the use of VTC expedites the process of identification and resolution of clinical and operational concerns in combat medical units in the field.  In addition, the meetings provide the forum for clinicians and nurses providing care to wounded service members to receive expert recommendations from neurology trauma specialists related to combat related TBI.  Upon evacuation of patients from combat medical units to military medical centers, the use of VTC is utilized by clinicians as soldiers are transitioned from acute care settings to receiving rehabilitation facilities.  The goal of this telecommunication method is to ensure continuity of care between VA and military medical sites.  This coordination effort is crucial to TBI patients whose recovery process is often unpredictable and often complicated by medical treatments and follow-up surgical procedures.

Advantages of the Proposed Solution

Health information exchange systems enable medical professionals to meet high standards of health care deliverance with multiple providers through electronic participation in a patient’s coordination of care.  “The VHA Polytrauma Telehealth Network, led by the VHA Office of Care Coordination (OCC) in Washington, DC, takes this concept one step further by establishing interactive connections between clinicians at four VA polytrauma centers and twenty one level ll VA medical centers (VAMCs) across the country” (Girard, 2007).  The goal of the Polytrauma Telehealth Network is to coordinate educational resources and national trauma rehabilitation for patients in the recovery process following a traumatic brain injury.  These electronic systems facilitate the continuum of care process from the initial injury to the rehabilitation process and home care support.

Military and veteran service members encounter unique challenges following traumatic brain injury.  The complexity of injuries resulting from hostile combat missions can be difficult to overcome. A challenge in the military community is to guarantee that educational programs are incorporated into the rehabilitation process for afflicted service members.  As a result of limited financial reserves, geographical barriers and time constraints, participation in educational programs may only be attainable through VTC and Web-based programs.  To address the various educational needs of TBI survivors, the TBI community has launched a selection of programs offered through the civilian and military communities as well as national brain injury centers and associations.  Creating an educational and supportive environment with a population of people with similar traumatic injuries, combat experiences, and military status is crucial to their physical and psychosocial wellbeing.

Clinical consultation utilizing video teleconferencing technology and the World Wide Web is considered the most widely used application of telemedicine in modern society.  It provides the forum for rendering specialized medical evaluations across distant boundaries.  Tele-consultation fosters interactive communication between providers, nursing staff, and patients by means of e-mail, video technology, audio tools, and still images with “store-and-forward” capability.  The United States military views teleconsultation as the lifeline that enables clinicians and nurses to provide specialized medical care of service members in the war zone.

Disadvantages of the Proposed Solution

In some instances, disruptions in telecommunication can hinder the sustainment of interactive video teleconferencing.  Therefore, consultation utilizing the World Wide Web’s inclusive e-mail capabilities and “store-and-forward” technology bridges the gap between technical imprisonment and technological empowerment.  A consultation program implemented by the military connects providers overseas with TBI specialists in the United States in support of critically injured soldiers.  Future plans are in progress to create a TBI program that will connect expert brain injury consultants with deployed nurses and clinicians at the immediate point of care.

Recommendations for Nursing Practice

Telemedicine is a complex system that requires the expertise of professional nurses.  Therefore, it is highly recommended that nurses utilizing telehealth systems remain vigilant in maintaining clinical proficiency in this advanced technical health care delivery process.  Patients inflicted with severe TBI generally require comprehensive nursing care.  Telemedicine is recommended to nursing practice as an assistive technology expanding the reach of health care professionals to remotely evaluate patients from a distance through the use of video teleconferencing, the internet, and personal telephone.  With the addition of remote monitoring devices, nursing professionals have the capability to relay vital signs and significant health related findings to distant health care clinicians in real time.

Conclusion:

In conclusion, considerable progress has been made towards the development of a multifaceted national telemedicine program.  This technology has enabled clinicians and nurses providing care in remote locations to receive expert recommendations from neurology trauma specialists related to combat associated TBI.  As a result of the multitude of service members inflicted with head injuries, there is a critical need for rapid identification of TBI, improved quality of care and follow up surveillance.  In turn, due to the limited availability of TBI specialists to meet the demands of the combat wounded, clinical management through telemedicine can improve survival rates and decrease long term physical and psychosocial deficits. 

Traumatic brain injury is a considerable health concern that has not been thoroughly investigated.  Therefore, the clinical research data currently in existence is limited.  Past and present studies indicate that rapid identification and specialized treatment of traumatic brain injury in military combat environments can help minimize the spectrum of associated devastating outcomes and inclusive lifelong physical, cognitive, and psychosocial impairments.  Telemedicine enables medical professionals to meet high standards of health care deliverance with multiple providers through electronic participation in a patient’s coordination of care.  The United States Department of Defense views teleconsultation as the lifeline that enables healthcare professionals who are geographically separated from specialized providers to deliver specialized medical care to service members in remote locations.

References

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• Martinez, R. N., Hogan, T. P., Lones, K., Balbale, S., Scholten, J., Bidelspach, D., … Smith, B. M. (2017). Evaluation and Treatment of Mild Traumatic Brain Injury Through the Implementation of Clinical Video Telehealth: Provider Perspectives From the Veterans Health Administration. PM & R: Journal of Injury, Function & Rehabilitation, 9(3), 231–240. https://doi.org/10.1016/j.pmrj.2016.07.002
• Schoenberg, M. R., Ruwe, W. D., Dawson, K., McDonald, N. B., Houston, B., & Forducey, P. G. (2008). Comparison of functional outcomes and treatment cost between a computer-based cognitive rehabilitation teletherapy program and a face-to-face rehabilitation program. Professional Psychology: Research and Practice, 39(2), 169–175. https://doi.org/10.1037/0735-7028.39.2.169
• Telemedicine in 2010: Robotic Caveats. (2010). The Lancet Neurology , 9, 1046.
• Yurkiewicz, I. R., Lappan, C. M., Neely, E. T., Hasselbrock, R. R., Girard, P. D., Alphonso, A. L., et al. (2012). Outcomes From A US Military Neurology and Traumatic Brain Injury Telemedicine Program. Neurology , 79 (12), 1237-1243.