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AMBULANCE TELEMETRY
                 Jirawat Juengsiragulwit
       Sappasitthiprasong hospital, Ubon
Disclosed
Outline

• Telemedicine

• Ambulance telemetry

• Ubon model and the key success to ambulance telemetry
Telemedicine (โทรเวช)

• The use of medical information exchanged from one
  site to another via electronic communication to
  improve patients'health status.
Telemedicine services

• Specialist referral services

• Remote patient monitoring

• Patient data transfer

• Medical education

• Consumer medical and health information
• Tele-radiology       • Tele-ambulance

• Tele-pharmacy        • Tele-ACS

• Tele-dermatology     • Tele-stroke

• Tele-ophthalmology   • Tele-trauma

• Tele-pathology

• Tele-consultation
2515 สมเด็จพระศรีนครินทราบรมราชชนนี ทรงพระกรุณาโปรด
เกล้าฯให้ดําเนินงานหน่วยแพทย์ทางวิทยุครั้งแรกในประเทศไทย
พระราชทานนามว่า...


       “แพทย์อาสาทางอากาศ”
Pass about 40 years

• Advance in mobile device technology




• Advance in social network communication
ICU mobile
อดีต = ICU ติดล้อ       +




ปัจจุบัน = ICU ติดปีก   +
Ambulance Telemetry

• Evaluate, Diagnose, Monitoring, Treat

• Patient in mobile bed

• from remote location or prehospital area

• Data roaming via telecommunication
Lifebot project, under US army development

• Telemedicine life support system

• Texas : $14 million advanced EMS ambulance
  telemedicine and disaster manage system.

• Important in remote areas where transport times may be
  prolonged ; act to protect ambulance personal and
  providers during difficult situations.
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Why ambulance needs telemetry?

• Moving vehicle needs continuous data transmission

• Complex clinical scenearios

• Difficult to interpret EKG rhythms

• Assistance in patient monitoring

• Destination decisions

• Assistance with-non transports
COMPOSITIONS

• Data roaming

• Medical device

• Encounter management

• Connectivity

• Hardware configuration
Data roaming

• Text

• Picture

• Voice

• Video
Medical device

• Lifegain : Defibrillator with Bluetooth.

• Camera set

• Notebook + air card for Internet access

• Workstation computer server
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Encounter management software

• EMS12 MultiviewerDual

• Text/Message chat

• EKG realtime with 2 second delay

• Snap shot picture 2 pics./sec.

• Voice IP
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Ambulance telemetry - Ubonratchathani
Connectivity (wireless computer network)

1.Global System for Mobile communication

   • General Packet Radio Service

   • Enhance Data rate for Global Evalution

2.Code Division Multiple Access communication

3.Wideband Code Division Multiple Access communication

4.WiMAX
CDMA
Ambulance telemetry - Ubonratchathani
Clinical effectiveness

• Monitoring

• Critical decision and management

• From "what's coming in the door"

 To "I knew and I'm waiting you"

 Now then "OK, you've already treated."
Old tradition
Some private hospital
UBON
Megaproject
Tablet + 3G = วาระแห่งปี
Brief history of Ubon ambulance transfer

• Zone 13 = 56 Hospitals (อุบลศรีโสธรเจริญ)
  Cover : อุบลราชธานี, ศรีสะเกษ, ยโสธร, อํานาจเจริญ

• อุบลราชธานี = 25 districts

• Before 2549 : BLS ambulance

• October 2549 : Super ALS ambulance

• October 2552 : mini-telemetry ambulance

• Since April 2553 : full option telemetry ambulance
UBON model

• 3 fast tract transfers : STEMI, Stroke, Trauma

   STEMI was sent as bypass tract

• Advance in specialized patient care have increased the
  demand for data communication system.

• We first applied in STEMI patients monitor during
  interfacility transfer
Ambulance telemetry - Ubonratchathani
Upcoming

• Ambulance telemetry protocol

• ICU mobile nurse training program

• Apply social network in advance communication
  "Referral data registry"

• Add distributive collaboration to online medical control
Ambulance telemetry - Ubonratchathani
Not only EP can be online medical control

• Real time evaluation and management of critically ill
  patients by multiple specialist.

• Assembly of multiple-victim information

• Assistance in diagnostics

• Transfer of care hand-offs

• Homeland security command and control
Key to a successful ambulance telemetry
1. Establish a vision

• How to increase the volume of service?

• Explore overall vision of the organization

• Model approach

	 	 - Access to care model

	 	 - Cost savings model

	 	 - Access to market model
December 2553

• 501 critic patients was transfer by ambulance telemetry

• 91.42% by overall critical interfacility transfer

• 72% applied telemetry during transfer
2. Building a long term financial plan

• Set short and long term financial goal.

• Looking for ongoing revenue (long term sustainability)

• You do not always get what you want but you often get
  what you measure.

• Show clear outcome and how to collect it
• The death rate in severe traumatic patients who inter
  facility needed was reduce from 37% to 31%

• Ongoing research

  1. Unit cost

  2. Compare clinical outcome
3. Create a convenient and effective work
environment

• The sending room : device position, lighting and white
  balance.

• The receiving room (workstation) : directly to consulting
  physician's workplace or using forward software to
  physician desktop.

• Simple as possible to use first, technology should be
  remain in the background.
Ambulance telemetry - Ubonratchathani
4. Mainstream telemedicine into the standard care
process

• Standard protocol for telemedicine as same as non-
  telemedicine

• Add : equipment protocol, dispatch, documentation,
  measurement and billing protocol

• The more change that must be adopted the higher the
  likelihood of failure
Criteria for activated ambulance telemetry

• Respirator needed         • Major trauma

• Impending compromise      • >2 episodes seizure in 30
  airway                      mins

• Acute coronary syndrome   • AOC protocol

• Shock or impending        • Obstetric protocol

• HT emergency              • Doctor order
5. Plan and assure effective training

• Communication technology

• Clinical technology

• Diagnostic device user training for both send and receive sites

• Workflow and protocols of care and procedures for use of
  devices

• Documentation

• Trouble shooting and access to product and technical support
Ambulance telemetry - Ubonratchathani
6. Make sure you have a full time coordinator and
an effective leader and cheerleader

• Clear leader in authority and fly cover the program
  participate.

• Key man : necessary skills, passion and commitment to
  serve, encourage user, inform management and assure
  that the program is properly marketed.

• Full time nurse and technician

• Sending sites person
Key persons
7. A project plan = manageable milestones =
Reasonable expectation

• Roadmap should be simple, manageable and reasonable

• Do not over plan and paralyze the project

• Set 5y plan, 10y plan, 20y plan and meet them
New project release

• 5yr : ICU mobile hub, Referal data registry

• 10yr : อุบลศรีโสธรเจริญ

• 20yr : 3D, Robot
8. Horizontal vs. Vertical implementation

• Limited capable but widely use or limited use but super
  capable

• Consider device option and clinical outcome.

• Telemet needs continuous train and support

• Both tract will reach a future large-scale expansion
9. Good market is clinical

• Set public expectations

• Tell the world the good things you've done

• Tell the world what is coming next
10. Publish or perish

• Presenting or publishing the results or status of our
  program at least once per year

• Posters, teaching and sharing
Ambulance telemetry - Ubonratchathani

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Ambulance telemetry - Ubonratchathani

  • 1. AMBULANCE TELEMETRY Jirawat Juengsiragulwit Sappasitthiprasong hospital, Ubon
  • 3. Outline • Telemedicine • Ambulance telemetry • Ubon model and the key success to ambulance telemetry
  • 4. Telemedicine (โทรเวช) • The use of medical information exchanged from one site to another via electronic communication to improve patients'health status.
  • 5. Telemedicine services • Specialist referral services • Remote patient monitoring • Patient data transfer • Medical education • Consumer medical and health information
  • 6. • Tele-radiology • Tele-ambulance • Tele-pharmacy • Tele-ACS • Tele-dermatology • Tele-stroke • Tele-ophthalmology • Tele-trauma • Tele-pathology • Tele-consultation
  • 8. Pass about 40 years • Advance in mobile device technology • Advance in social network communication
  • 9. ICU mobile อดีต = ICU ติดล้อ + ปัจจุบัน = ICU ติดปีก +
  • 10. Ambulance Telemetry • Evaluate, Diagnose, Monitoring, Treat • Patient in mobile bed • from remote location or prehospital area • Data roaming via telecommunication
  • 11. Lifebot project, under US army development • Telemedicine life support system • Texas : $14 million advanced EMS ambulance telemedicine and disaster manage system. • Important in remote areas where transport times may be prolonged ; act to protect ambulance personal and providers during difficult situations.
  • 14. Why ambulance needs telemetry? • Moving vehicle needs continuous data transmission • Complex clinical scenearios • Difficult to interpret EKG rhythms • Assistance in patient monitoring • Destination decisions • Assistance with-non transports
  • 15. COMPOSITIONS • Data roaming • Medical device • Encounter management • Connectivity • Hardware configuration
  • 16. Data roaming • Text • Picture • Voice • Video
  • 17. Medical device • Lifegain : Defibrillator with Bluetooth. • Camera set • Notebook + air card for Internet access • Workstation computer server
  • 20. Encounter management software • EMS12 MultiviewerDual • Text/Message chat • EKG realtime with 2 second delay • Snap shot picture 2 pics./sec. • Voice IP
  • 29. Connectivity (wireless computer network) 1.Global System for Mobile communication • General Packet Radio Service • Enhance Data rate for Global Evalution 2.Code Division Multiple Access communication 3.Wideband Code Division Multiple Access communication 4.WiMAX
  • 30. CDMA
  • 32. Clinical effectiveness • Monitoring • Critical decision and management • From "what's coming in the door" To "I knew and I'm waiting you" Now then "OK, you've already treated."
  • 35. UBON
  • 37. Tablet + 3G = วาระแห่งปี
  • 38. Brief history of Ubon ambulance transfer • Zone 13 = 56 Hospitals (อุบลศรีโสธรเจริญ) Cover : อุบลราชธานี, ศรีสะเกษ, ยโสธร, อํานาจเจริญ • อุบลราชธานี = 25 districts • Before 2549 : BLS ambulance • October 2549 : Super ALS ambulance • October 2552 : mini-telemetry ambulance • Since April 2553 : full option telemetry ambulance
  • 39. UBON model • 3 fast tract transfers : STEMI, Stroke, Trauma STEMI was sent as bypass tract • Advance in specialized patient care have increased the demand for data communication system. • We first applied in STEMI patients monitor during interfacility transfer
  • 41. Upcoming • Ambulance telemetry protocol • ICU mobile nurse training program • Apply social network in advance communication "Referral data registry" • Add distributive collaboration to online medical control
  • 43. Not only EP can be online medical control • Real time evaluation and management of critically ill patients by multiple specialist. • Assembly of multiple-victim information • Assistance in diagnostics • Transfer of care hand-offs • Homeland security command and control
  • 44. Key to a successful ambulance telemetry
  • 45. 1. Establish a vision • How to increase the volume of service? • Explore overall vision of the organization • Model approach - Access to care model - Cost savings model - Access to market model
  • 46. December 2553 • 501 critic patients was transfer by ambulance telemetry • 91.42% by overall critical interfacility transfer • 72% applied telemetry during transfer
  • 47. 2. Building a long term financial plan • Set short and long term financial goal. • Looking for ongoing revenue (long term sustainability) • You do not always get what you want but you often get what you measure. • Show clear outcome and how to collect it
  • 48. • The death rate in severe traumatic patients who inter facility needed was reduce from 37% to 31% • Ongoing research 1. Unit cost 2. Compare clinical outcome
  • 49. 3. Create a convenient and effective work environment • The sending room : device position, lighting and white balance. • The receiving room (workstation) : directly to consulting physician's workplace or using forward software to physician desktop. • Simple as possible to use first, technology should be remain in the background.
  • 51. 4. Mainstream telemedicine into the standard care process • Standard protocol for telemedicine as same as non- telemedicine • Add : equipment protocol, dispatch, documentation, measurement and billing protocol • The more change that must be adopted the higher the likelihood of failure
  • 52. Criteria for activated ambulance telemetry • Respirator needed • Major trauma • Impending compromise • >2 episodes seizure in 30 airway mins • Acute coronary syndrome • AOC protocol • Shock or impending • Obstetric protocol • HT emergency • Doctor order
  • 53. 5. Plan and assure effective training • Communication technology • Clinical technology • Diagnostic device user training for both send and receive sites • Workflow and protocols of care and procedures for use of devices • Documentation • Trouble shooting and access to product and technical support
  • 55. 6. Make sure you have a full time coordinator and an effective leader and cheerleader • Clear leader in authority and fly cover the program participate. • Key man : necessary skills, passion and commitment to serve, encourage user, inform management and assure that the program is properly marketed. • Full time nurse and technician • Sending sites person
  • 57. 7. A project plan = manageable milestones = Reasonable expectation • Roadmap should be simple, manageable and reasonable • Do not over plan and paralyze the project • Set 5y plan, 10y plan, 20y plan and meet them
  • 58. New project release • 5yr : ICU mobile hub, Referal data registry • 10yr : อุบลศรีโสธรเจริญ • 20yr : 3D, Robot
  • 59. 8. Horizontal vs. Vertical implementation • Limited capable but widely use or limited use but super capable • Consider device option and clinical outcome. • Telemet needs continuous train and support • Both tract will reach a future large-scale expansion
  • 60. 9. Good market is clinical • Set public expectations • Tell the world the good things you've done • Tell the world what is coming next
  • 61. 10. Publish or perish • Presenting or publishing the results or status of our program at least once per year • Posters, teaching and sharing