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L. B. Nosanov and A. Cochran
372
b, c
Outpatient burn center
referral recommended
• Not specifically indicated
c
available
• Recommended if
Telemedicine consultation
recommended
a, b
Patient transfer potentially indicated
T . (continued)
Toxic Epidermal Necrolysis (TENS)
with epidermal slough
• Stevens–Johnson syndrome (SJS) or
Non-
burn skin
(NSTI)
• Necrotizing Soft-Tissue Injury
disorders
the wound care, rehabilitation,
and healing expertise of the
multidisciplinary burn team.
– These patients benefit from
This document represents the consensus of burn care stakeholders’ experience and opinion on which patients likely
a
benefit from burn center care. It is NOT intended to replace throughtful provider-to- provider conversation based on
the individual needs of each patient and is not prescriptive. Many factors, including geography and patient preferences,
must be considered when making triage decisions
Burn centers contain specialist providers of all kinds, including specialty trained nurses, rehabilitation therapists, dieti-
b
Telemedicine is an effective tool to improve the triage and care of burn patients. It should be used to support the tri-
cians, physicians, and psychosocial support staff. The availability of these resource should be a factor in all patient triage
decisions, based on the patient’s needs
c
age and transfer decision-making process between providers whenever possible and is particularly helpful in reducing
over-triage of small deep burns and in promoting accurate %TBSA estimation
Chapter 17. Telemedicine
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373
Much of the current literature on utilization of telemedicine
for management of burn injuries focuses on reduction of
unnecessary transfers through improved triage [6, 17, 20, 21].
Transfers are costly and utilize scare resources, particularly
those that are long distance and require air transport. It is not
uncommon that inappropriately triaged patients undergo
unnecessary travel to a burn center to be discharged immediately or after a brief hospital stay. While over-triage is
reported in both adult and pediatric patients, the rate is significantly higher among children than adults [6]. Specifically,
Reiband et al. found that the over-triage rate was highest
among children less than 2 years old suffering scald burns
[34]. McWilliams etal. performed an eight-year retrospective
study of rural pediatric patients evaluated by telemedicine
showing that improved triage of 4068 patients whose burn
wounds that were reviewed resulted in only 364 acute transfers [20].
In a retrospective review of patients with small burns,
Boccara et al. found telemedicine consultation was highly
effective for identification of the presence of injuries with a
surgical need that therefore warranted transfer [35]. In this
study only 34.7% of patients required transfer, of which 3.4%
were deemed unnecessary in that patients did not ultimately
undergo surgery. A telemedicine quality improvement effort
at a regional burn center serving a catchment including eight
states found that the addition of image review to initial phone
consultations changed transfer decisions for 24.5% of the
study population [5]. Of these, 60.5% were down-triaged
while 39.5% were up-triaged.
A recent study by Carmichael etal. evaluated the effect of
a mobile phone app on triage and transfer of patients to a
burn center from regional referring institutions [33].
Comparisons were made to patients referred during the same
time frame via a call center without use of the burn mobile
phone app. Patients were considered “down-triaged” after
telemedicine evaluation if they were determined to be appropriate for outpatient management or transport by personal
vehicle as opposed to ground ambulance or helicopter.
374
L. B. Nosanov and A. Cochran
Overall, one-third of patients evaluated with the burn mobile
phone app were able to be down-triaged, with a resultant
average cost savings of $634 per patient. In comparison, no
patients managed without telemedicine were able to be
down-triaged. Based on their experience, the authors concluded that telemedicine most greatly impacted the triage of
patients with burns greater than 1% TBSA and less than 10%
TBSA.
A similar investigation by Saffle etal. compared triage and
transfer of patients managed prior to implementation of a
telemedicine referral program and after [4]. All patients
determined to require transfer prior to the telemedicine program implementation were transported to the regional burn
center by air. In comparison, approximately half of the
patients evaluated initially by telemedicine consultation were
able to avoid the need for air transport. While a small proportion were transferred via private vehicles, several were determined not to require transfer at all and were able to receive
all care locally. The authors additionally concluded that telemedicine consultation enhanced the allocation of critical care
resources and expedited transfer of severely injured patients.
Rapid and accurate identification of these critical patients
was also felt to help justify the risks and cost of air
transport.
With the diminished need for travel and a decrease in
travel-related costs without a perceived compromise in delivered care, multiple studies have found high levels of patient
satisfaction [21, 23, 36]. One study demonstrated that based
on medicare reimbursement rates, an average of $910 could
be saved for those transferred by private vehicle or local
management and $83 could be saved in driving costs for those
who could be managed by their local primary care physician
[33]. Hickey et al. performed a retrospective review of
patients participating in interactive home telehealth visits for
follow-up burn care and identified a travel distance save of
188miles per patient, equivalent to 201 min of travel time,
resulting in an average savings of $108.50 [23].
Chapter 17. Telemedicine
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375
A satisfaction survey administered by Liu etal. noted that
respondents were pleased with both diminished time and
money spent to achieve follow-up with their burn providers
[24]. They also found that providers’ ability to share their
screen through their telemedicine interface was positively
received by patients. Allowing patients to view images of
their own wounds and grafts facilitated conversation and
increased patients’ sense of active participation in their own
care. Similar benefits can also be observed through study of
the rehabilitative phase of care [20, 24]. Liu etal. found that
utilization of a telemedicine rehabilitation program saved 146
ambulance transports (for a cost of $101,110), 6.8 outpatient
burn clinic days, and 2–3days of patient travel. Beyond these
measurable outcomes, the authors felt that incorporating
telemedicine improved burn center providers’ relationships
with care team members at the local rehabilitation hospital.
With introduction and maintenance of telemedicine
programs, there are a number of administrative considerations.
All telemedicine must follow both ethical and legal best practices [15]. The American Telemedicine Association recently
published a policy guide for the use of telemedicine in the
practice of burns [37]. Emphasis is placed on compliance with
relevant local, state, federal, and international laws and regulations, including prescription practices. Providers must follow policies and standard operating procedures of governing
institutions or otherwise establish appropriate policies and
procedures if functioning within a private or solo practice.
Documentation standards require careful review, particularly
given their application to billing purposes.
Systems must be secure and prioritize privacy and
confidentiality of patient data in accordance with the Health
Insurance Portability and Accountability Act (HIPAA) [22].
Providers need to be appropriately credentialed and trained
and clinical oversight must be provided where applicable.
Programs designed for referral and consultation should have
adequate staffing to allow for availability at any time of the
day or night. Platforms should be designed to keep up with
technological advancement. System function and perfor-
376
L. B. Nosanov and A. Cochran
mance must have ongoing monitoring and evaluation. Further,
burn center management should facilitate processes of quality assurance, audit, and research for a telemedicine program
to thrive.
remained an ongoing challenge. While the 1997 Balanced
Budget Act required Medicare reimbursement of telemedicine visits, this did not translate into direct remuneration of
providers. Required reimbursement by Medicare, Medicaid,
and the State Children’s Health Insurance program was
expanded by the 2000 Benefits Improvement and Protection
Act, though applicability was limited. Current regulation is
primarily on a state-by-state basis. A roadblock for institutions looking to establish and maintain a telemedicine program is the need to determine a plan for solvency. Notably,
Russell etal. found that in transitioning support for a telemedicine program beyond a grant reimbursement was similar
for in-person and telemedicine patients [38]. Familiarity with
coding specific to telemedicine is also crucial [1].
A number of barriers to successful adoption and usage of
a telemedicine in burns exist. The main obstacles to implementation of a burn telemedicine program cited by Monte
Soldado etal. were the need to maintain a reliable and complex technical infrastructure, establishment of a training program for involved providers, and ongoing coordination and
logistics [39]. The most common barriers to successful establishment and maintenance of a telemedicine program cited
by burn center directors were licensure, credentialing, and
malpractice considerations [22]. These issues become increasingly problematic if a center’s catchment area extends
beyond state borders, raising the potential need for practitioners to obtain and maintain licensure in multiple states.
There is significant provider and healthcare system
reluctance to adopt new technology [4]. In a 2014 review of
telemedicine in burn care, Atiyeh etal. note that the culture
of medicine has created a trend for healthcare providers to be
Chapter 17. Telemedicine
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377
suspicious and fearful of new technology [1]. While this roadblock has resolved gradually over time, the most significant
catalyst for adoption and propagation of telemedicine programs has been the emergence of the 2019 novel coronavirus
(COVID-19). The pandemic has indelibly changed practice
patterns surrounding use of telemedicine in burn care [40].
Burn centers have had to rework multidisciplinary management plans with wide adoption of telemedicine particularly in
the outpatient setting due to limitations on direct personal
contact [41]. One algorithm released several months into the
pandemic included teleconsultation for guidance and follow up of minor burn injury and also advocated for post-discharge
recovery guidance; the same authors also emphasized the
importance of using teleconsultation for triage and clinical
decision-making prior to patient transfer during the pandemic [42].
However, not all clinical situations are appropriate for
telemedicine. Patients requiring evaluation of concurrent
non-burn injuries must be assessed in person with availability
of required personnel and imaging technology. Scar assessment and management are highly challenging without the
ability to consider palpation findings. Long-term scar management also typically requires measurement and fitting of
custom compression garments, facemasks, and splints which
necessitate face-to-face evaluation [1]. Evaluation for surgery
for both acute burns and reconstruction can be initiated via
telemedicine but ultimately requires in-person presentation
for comprehensive planning.
Use of telemedicine, while imperfect, can contribute
meaningfully to the care of burn patients. While COVID-19
has resulted in the more rapid and widespread adoption of
telemedicine in burn care, these changes will hopefully prove
to be durable care processes once the pandemic recedes.
Telemedicine provides a powerful medium for certain aspects
of burn care, particularly initial triage and management, and
is an important adjunct for provision of high-value burn care.
378
L. B. Nosanov and A. Cochran
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