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: [email protected]