Vikki Snaith-NUTH

SC Robson, A Marshall, VJ Snaith, R Graham, M Lie,
M Matar, D Moga, A Henderson
Background to project
 Key component of antenatal care is to identify the ‘at risk’ fetus.
 Women referred by sonographer to local specialist or FMU when
problem identified during scan.
 Specialist fetal medicine services concentrated in regional fetal
medicine centres.
 Telemedicine has the potential to provide specialist obstetric
ultrasound and specialist consultation to women distant from
specialised centres (e.g. Cumbria).
 The technology can be used to provide on-site training for local
sonographers in ‘advanced’ ultrasound investigations (e.g. fetal and
maternal Doppler).
Evidence of effectiveness
 Previous UK studies have shown that successful transmission of high
quality ultrasound with live guidance, followed by counselling by
videoconferencing is achievable in the majority of cases [1,2].
 Even with smaller sized internet connections than now available,
image quality was sufficient for diagnosis in >95% of cases [1].
 The use of telemedicine was highly acceptable to patients with
women expressing a preference for telemedicine consultation
compared to face-to-face [2].
[1] Fisk NM et al. BJOG 1996; 103: 1092-5; [2] McCrossan BA et al. Prenat Diagn 2012,
12: 883-7.
Innovation
 NUTH has invested in state-of-art videoconferencing facilities, currently
there is no telemedicine service between Cumbria and Newcastle.
 Despite clear evidence of the effectiveness of the technology, a fetal
telemedicine service has not been developed in the UK outside of small
projects.
 Opportunities to dramatically alter the way FM services are offered
throughout Cumbria and improve care.
 Mechanism for providing specialised obstetric ultrasound services and
upskilling sonographers.
 Successful implementation of the technology should be seen as ‘proof of
principle’ and wider use of the innovation in other clinical areas would
follow.
Project aims
 To establish a videoconferencing infrastructure between the
obstetric ultrasound unit at West Cumberland Hospital and the
Fetal Medicine Unit in Newcastle.
 To determine the technical success of the service.
 To evaluate the success of utilising the telemedicine technology for
training sonographers
 To assess women’s views of using a telemedicine ultrasound service,
including family costs.
 To assess the benefits and barriers to adoption of the service across
Cumbria.
Partnership working
 This project brings together health professionals and
academics from all 4 partner organisations with relevant
expertise, many of whom have worked together on prior
projects.
 Strong clinical and teaching/training links already exist
between the obstetric departments at NCUH and NUTH
with established referral pathways for complex fetal
problems.
 The project will further develop these clinical and
academic links.
Collaboration
 Prof S. Robson, Professor of Fetal Medicine, Newcastle University
 Dr R Graham, Senior Lecturer, School of Sociology, Newcastle University
 Dr M. Lie, Research Associate, Newcastle University
 Prof A Marshall, Professor of Health Technology & Innovation, University of Cumbria
 Mr M Matar, Clinical Director, North Cumbria University Hospitals NHS Trust
 Mr D Moga, Consultant Obstetrician, North Cumbria University Hospitals NHS Trust
 Mrs A Henderson, Lead Obstetric Sonographer, North Cumbria University Hospitals
NHS Trust
 Dr V. Snaith – Senior Research Midwife/Sonographer, The Newcastle upon Tyne
Hospitals NHS Foundation Trust
 Mr R. Beckwith, Data and Telecoms Manager, The Newcastle upon Tyne Hospitals NHS
Foundation Trust
Potential impact of project
 Reduction in the number of women required to travel to Newcastle for
specialist fetal ultrasound.
 Reduction in associated family costs.
 Improved prenatal diagnosis and management of high risk fetuses by
increasing access to specialist fetal medicine care.
 Enhanced standard of local obstetric ultrasound by developing local
sonographers through telemedicine training.
 Evidence that a fetal telemedicine service is acceptable to parents and to
health professionals
 Engagement of key local stakeholders and provision of robust evidence as
to how the fetal telemedicine service can be implemented across a wider
geography and potentially across additional clinical areas.
Evaluation of telemedicine service
 Number of telemedicine consultations (together with
indications) as a proportion of all FM cases /
consultations referred from WCH.
 Technical success of every new consultation - success
will be defined as an ultrasound image quality sufficient
to make a definitive prenatal diagnosis.
 Cost impact - cost components for the NHS including
consultation times and staff utilisation.
Patient Evaluation
 All women who have had a telemedicine scan will be
asked to complete a questionnaire to assess their views,
acceptability and family costs.
 Sub-sample of women (n=10-15) will be asked to take
part in a telephone interview to gain greater insight.
Sonographer training
 Training of local sonographers will be undertaken at WCH
during 20 week anomaly scans (for uterine artery Doppler)
and fetal growth scan (for middle cerebral artery Doppler).
 After an initial tutorial (via videoconference) and assessment
of baseline skills, supervised training will be undertaken.
 Sonographers will be deemed competent when five successful
Objective Structured Assessments of Training (OSATs) are
completed for each technique.
Stakeholders
• Information on the benefits and barriers to adoption of
the service collected by using The Stakeholder
Empowered Adoption Model, by identifying and
contacting key decision makers.
• Stakeholder interviews (face-to-face and telephone)
• Determine how they are influenced by other
stakeholders and what evidence they would like to see
from the evaluative implementation.
• Ensure a decision can be made at the end of the
project.
Project timeline
2014
July
Aug
Sept
2015
Oct
N D
J
F
Project set up
Sonographer
training
Telemedicine
consultations
Evaluation
questionnaires
Evaluation
Interviews
Write up,
assimilation and
feedback
Project
suspended
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Progress
 Audit of fetal medicine referrals to determine the incidence and indication for
referral
 Referral plan has been devised, detailing which cases are suitable for telemedicine
service and the timeframe for increasing the complexity of cases.
 Training – following consultation to determine sonographer training needs,
sonographer training programme has been developed including a training manual
and OSATS.
 Regular project management group meetings
 Patients – The patient evaluation questionnaires and interview topic guide have
been designed and a favourable opinion has been given by LREC. The patient
questionnaire has been piloted for face validity with service users.
 Stakeholder interviews - contact with NHS managers (West Cumberland and
Morecombe Bay), clinical staff (sonographers and obstetricians), and contacts within
Cumbria CCG.
Challenges
 Initial failure to establish a videoconferencing link
between to RVI and WCH.
 Options explored:
 Direct Internet Access, N3, HIX
 Communication with senior managers at NCUH Trust
Ongoing strategy
 NUTH Radiology Directorate plan to establish a
videoconferencing link between the RVI and WCH to enable
delivery of the Breast Screening service by March 2015
 Two 100Mbp/s Trust links are being installed, a VC call at
most is 1Mbp/s.
 More than sufficient bandwidth to utilise this link without
compromising Breast Screening clinical service.
 Implementation of project delayed until March 2015
 Continued engagement with senior managers at NCUH
Thank you for
listening
Project funded by:
AHSN North East and North
Cumbria
Contact:
vikki.snaith@ncl.ac.uk