Issues Magazine

Ultra-Broadband Internet Use in Critical Care

By Patrick Cregan

Ultra-broadband technology has critical health applications in remote locations.

“Critical care” is the term applied to the care given to patients whose life or well-being is in immediate danger. This can be due to problems with breathing such as severe asthma, heart problems such as heart attacks, blood loss due to severe injuries, and low blood pressure from severe infections such as meningococcal disease and many other problems. In these situations, time is of the essence and patients need highly specialised teams of doctors and nurses to look after them.

Many small isolated hospitals across Australia lack critical care and other tertiary specialists. A relative shortage of doctors with the necessary skills and knowledge means that patients in remote locations may not get care equivalent to those in big city centres.

A system using ultra-broadband (second-generation) internet was established by the Wentworth Area Health Service (now Sydney West Area Health Service) and CSIRO to improve access to these services at Blue Mountains District Anzac Memorial Hospital. The resulting virtual critical care unit (ViCCU) aimed to provide rapid access to specialist-level decision support by clinicians at the peripheral hospital, including critical clinical situations up to and including the distant management of a cardiac arrest, by way of “effective tele­presence”.

“Telehealth” is the use of telecommunications technologies for two-way video linkage to provide health services to patients who are distant from the provider. These technologies have been around for many years but the uptake has largely been confined to psychiatry and renal medicine, where the type of interaction is “talking head” or store-and-forward processing of images for dermatology, radiology etc. This is due to the generally poor quality of the television images, the long latency in the interaction and the poor accessibility of the current equipment, all of which are ultimately due to technical constraints of bandwidth (see box, p.25).

In 2002, as part of the privatisation of Telstra, the Federal government provided monies through the Advanced Networks Programme to a number of consortia to explore the possibilities of high-bandwidth telecommunications – the so-called second-generation internet. One of the consortia was the CeNTIE network (Centre for Network Technologies in the Information Economy). This group, under the leadership of CSIRO, addressed the basic question: “If bandwidth were unlimited and cost virtually nothing, what would you do with it?” and looked at a number of applications in four groups:

  • education: developing the “virtual classroom”;
  • banking: making millions of small data set transactions;
  • post-production movie industry: sharing huge data sets and creating virtual enterprises around them; and
  • health: developing two projects, the ViCCU project and clinical meetings such as paediatric cardiology meetings with large data set sharing.

Of these, ViCCU (in collaboration with NSW Department of Health and Sydney West Area Health Service) and the post-production enterprise went on to fruition.

ViCCU uses an ultra-broadband connection (1000 Mb/s) based on fibre-optic cable that allows real-time audiovisual communication between clinicians at Anzac Memorial Hospital with emergency department specialists at Nepean Hospital. ViCCU transmits four real-time audio–video feeds. The Nepean specialist can be seen and heard on a cart monitor by the patient and Anzac Memorial Hospital staff. The Nepean specialist can simultaneously view three images of the patient at Anzac Memorial Hospital, choosing between end-of-bed, above-bed and roving camera feeds, the vital signs monitor and a document camera with X-ray viewing.

Critical care requires attention to some specific areas when a telemedicine system is used:

  • critical care has variable and unpredictable work patterns and complexity of patient loads;
  • staff involved are continually faced with stressful life-and-death situations in a busy and noisy environment;
  • much of the time, staff members in the team are engaged in overlapping conversations and doing many things simultaneously, but everyone needs to know what everyone else is doing;
  • most information transactions between team members are informal, and can include non-verbal communications such as gesture and facial expression, which need to be captured for effective teamwork; and
  • verbal communications involve very specific domain terms that are often very terse. The “shorthand” used has to be captured exactly, and thus background noise and echoes must be minimised.

Supporting such a situation requires a large flow of data (visual, audio, records such as paper charts and X-rays, and vital signs monitoring) to be available to the specialist continuously in real time. Hence multiple feeds must be available contemporaneously so that the user does not need to “change channel” to get necessary information. This is, in a way, analogous to the control room in a television station, where the director chooses the view that he or she wants from multiple available views. The multi-channel feeds available from ViCCU allow this in real time with minimal latency, and thus an effective telepresence is established.

The system has now been deployed for three-and-a-half years. Patterns of staffing have changed at Anzac Memorial Hospital such that the need for critical care use has declined in working hours, but its use continues unabated out of hours and for assessment of more minor problems.

The system was subjected to rigorous assessment by the University of New South Wales’ Centre for Health Informatics. Immediate benefits were noted upon implementation of the ViCCU in the emergency department at Anzac Memorial Hospital, with staff having access to specialist emergency medical consultation 24 hours per day, 7 days per week.

The project was evaluated over an 18-month, multi-method, before-and-after study incorporating qualitative and quantitative data collection in 350 critically ill patients. Statistically significant changes were found in patterns of patient separations, with less local admissions and more transfers of critically ill patients and a significant increase in the rate of discharges for minor trauma patients. Structured interviews showed that using ViCCU allowed clinicians to increase the decision support they provided to clinicians at Anzac Memorial Hospital.

Utilising the possibilities of ultra-broadband internet, ViCCU provides new and improved opportunities for clinicians to remotely communicate about patient management. It has won multiple national and international awards for technical excellence and remains the world’s best telehealth system. Currently, its uptake is impeded by the politics of broadband roll-out and a lack of resolve to adequately staff and fund the system so that it can be extended to Lithgow and the rest of rural NSW.

This is a very brief description of a large project. The use of second-generation internet and the corresponding improvement in quality and latency of the telehealth images over all other systems is best appreciated by seeing the system (