Saturation was achieved after eight interviews, with the last two interviews generating no significantly novel insights. Participants are referred to as coordinators, and quotations are presented with each participant’s identification number in square brackets [1–10]. Apart from the two coordination centres (Brisbane and Townsville), locations have been deidentified. The terms ‘telehealth’, ‘RSQ’, ‘videoconference’, and ‘VC’ were used interchangeably by participants.
Two key categories were identified, each with the same 3 themes, presented in Table 1. The categories were based on the structure of the interviews; however, the themes emerged directly from the data. Although the interview questions were focused on patient care, the data revealed that participants believe the main benefit of emergency telehealth is not better or more timely patient care, but supporting isolated clinicians through critical, high-stress, unfamiliar situations. However, supporting rural teams from a distance can be simultaneously rewarding and challenging. Coordinators may feel deeply responsible for what takes place in the rural facility, yet are powerless to step in when needed. This creates unique challenges when providing emergency telehealth support to rural teams. The first category presents these challenges in detail, and the second category describes how telehealth technology can help to overcome, but sometimes contributes to, these challenges.
Table 1
Categories and themes identified from interviews with medical coordinators about emergency telehealth support.
| 1.0 | Challenges of providing emergency telehealth support |
| 1.1 | Establishing and maintaining awareness of the rural situation |
| 1.2 | Supporting rural teams from a distance |
| 1.3 | Working within the constraints of local capacity and capability |
| 2.0 | How telehealth technology facilitates or limits emergency support |
| 2.1 | Establishing and maintaining awareness of the rural situation |
| 2.2 | Supporting rural teams from a distance |
| 2.3 | Working within the constraints of local capacity and capability |
1.0 Challenges of providing emergency telehealth support
1.1 Establishing and maintaining awareness of the rural situation. One of the main challenges of providing emergency telehealth support is understanding the clinical situation at the rural facility. Coordinators are typically notified via phone call that a rural team is requesting support, which prompts the videoconference. Most participants reported that the amount of background information provided by rural teams can vary substantially. Several participants recalled experiences where they were unable to obtain any background information prior to joining a videoconference, and had subsequent difficulties obtaining that information during the videoconference (e.g., understanding what led to a patient’s cardiac arrest and whether or not they presented with chest pain).
“In different cases there is often a tendency for rural facilities to panic and want you on telehealth straight away…You dial in to a scene that [appears to be] just utter chaos. You’re not sure who you’re talking to, where they are, there’s a patient that looks like a deer in headlights…If I could actually take the doctor from that situation to stand at the side of the room on a handheld phone and speak to me, I would get a clearer handover and a clearer idea of the situation.” [8]
Accessing information remotely often means verbally prompting for information. Several coordinators felt that having to prompt the rural team for information can be inefficient and disruptive for the rural team, particularly during high-stress scenarios.
“There were pieces of information that I had to prompt for that, perhaps, if I’d been there in the flesh, I could have just looked at myself. So, for example, ‘can you turn the vital signs monitor around, so I can see it properly?’” [2]
“It’s just hard to interrupt to get [information]. In the resus room you’d walk over to someone and look down onto their – what they’ve written and things like that, it’s the interrupting to get pertinent information.” [7]
Variability in background information prior to joining a videoconference, and difficulty extracting information during a videoconference, can make it harder to provide high-quality support to rural teams via telehealth.
1.2 Supporting rural teams from a distance. Several unique challenges come with providing remote, hands-off support. Despite not being present in person, coordinators generally feel responsible for the situation and its outcomes. Most coordinators feel very responsible, despite acknowledging that some things are outside of their control. However, these feelings of responsibility can depend on the role coordinators adopt and the seniority of the rural staff they are supporting. One coordinator felt that having someone else with whom to share patient management decisions is a primary benefit of emergency telehealth for rural clinicians.
“I feel responsible, but wouldn’t take any of the credit for the good work that was done. If anything were to have gone awry…Then I would have taken the responsibility for that.” [1]
“I had a guy who failed [intubation]. He failed in front of his staff. That makes it a complication for which I also need to protect that individual. There is a degree of responsibility there. There is a degree of responsibility to the colleague, the patient and staff and the system.” [5]
“Oh, I feel completely responsible. As soon as I’m involved in the care, I guess I feel as responsible as I feel when I have the patient in my department.” [10]
Some coordinators recalled rewarding experiences and feelings of pride, relief, and satisfaction after remotely guiding a rural team through difficult, high-stakes situations.
“I remember thinking, ‘oh, gee, that was a very challenging case. I’m really proud of myself for working out the logistics of getting aircrew and aircraft to that person’…I remember thinking, ‘gee, telehealth was very useful’…I felt like I’d done a challenging resuscitation and had achieved something.” [2]
“It was a meaningful case. It was a young woman who was critically unwell and at risk of dying. But also a case that handled well. There was an opportunity to make a big, positive impact.” [6]
However, providing support from a distance can be distressing for coordinators. Several coordinators recalled times where they could do nothing but observe what unfolded on their screen, while also knowing that the rural team may be without help for several more hours.
“It makes me want to cry now. I thought about that mum and when she came in and they said ‘it’s over’, just devastating. I think there was something really horrible about watching it, but not being part of it. I’d normally be the person delivering that news and you have some contact with them and stuff like that, but yeah, it’s horrible.” [7]
“We are essentially saying, ‘sorry, yes, we know you’re critically unwell, it’s going to take this long [for the retrieval team] to get to you’. Unless they are close to one of the bigger centres, like [northern Queensland cities], it usually is anywhere between three to eight hours.” [10]
Coordinators sometimes find that they have less command over telehealth, despite being the most senior person involved in the patient’s care. This can make it challenging to guide the rural team, with some coordinators describing situations where their instructions were not followed. This challenge is further exacerbated when supporting incohesive rural teams.
“There’s been a couple of times where you’ve felt that maybe you’ve not been as forceful about things as you might have been if you’d physically been there just because of – all [they] can hear is a voice, big brother, you can just hear this voice or you look up and see on the screen…It’s like co-pilot, pilot stuff of when do you take over? You can’t actually really because you’re not there.” [3]
“I’ve certainly had resuscitations where they are actually about to do something that they shouldn’t and I’m unfortunately yelling ‘stop, stop, stop’ and [it feels like] no one’s listening to me…I’ve had situations where the doctor has done the opposite to what I’ve said…The nursing staff were basically staring at me over the VC…So that’s quite difficult where you’ve got quite a fractured team because you don’t have that relationship with anybody in the room. It’s very difficult to support them.” [7]
Medical coordinators are on dedicated shifts whilst working for RSQ, where their sole responsibility is to the RSQ workload, including coordinating aeromedical retrievals and supporting rural teams. This in itself can increase the complexity of providing telehealth support as they manage multiple competing demands, including multiple videoconferences, retrieval coordination, and note-taking, simultaneously. RSQ nurses support coordinators with these tasks but they are not always available.
“I was supporting the nurses through managing [a snake bite], whilst at the same time also having a cardiac arrest in [rural hospital] on the other telehealth screen that we have at the coordination office. [Also] having another phone call about a trauma, and the trauma was the relatively minor part of all of this.” [1]
“If I translate the normal practice in the ED, for example, for a cardiac arrest, I’m giving instructions, drug doses, whatever it is, someone is writing them down for me. Whereas, often, that doesn’t happen in telehealth...I’m writing down here, while I’m talking up [here].” [2]
Coordinators providing support from a distance must balance their strong feelings of responsibility with a lack of physical presence. A virtual-only presence can reduce coordinators’ perceived authority compared to critical events attended in-person, and can mean that coordinators are not able to provide their entire attention to the event.
1.3 Working within the constraints of local capacity and capability. A further challenge of providing emergency telehealth support is that coordinators need to understand the local capacity and capability, which varies widely across rural facilities, and tailor their support to fit within these conditions. Coordinators commonly mentioned that they do not know the team they are supporting or the resources in the local facility, which limits the support they can provide.
“The constraints were sort of around pretty standard equipment in the hospital…‘Oh, we don’t have a BIPAP’, ‘well, yes, you do, but you don’t have the masks’. Like, Jesus…I remember thinking, ‘how the hell could a hospital not have a BIPAP mask?’” [2]
“I won't know them, they won't know me. I’ll have no idea of anybody’s skillset or experience…You’re obviously remote and not having, you know, having only met for the first time, I won't know any of the staff names which helps the communication and task delegation and closed loop communication.” [9]
“So that’s probably the major limitation. Lack of knowledge about the skill set of the treating clinicians there, which then affects your ability to determine how far you should push them…Particularly in critical situations like this, you can only get the best out of the team that you have got…Yes, I know I’m probably adding value by providing support to the clinician, but I don’t feel I’ve done everything that I could do, in an ideal world.” [10]
Not knowing the rural team can also affect the extent to which coordinators feel they are kept ‘in the loop’ and included as a team member, which then affects their ability to tailor the support they provide to be of most value. In some cases, coordinators may be concerned that they are making incorrect assumptions about what has or has not been done or missing information such as subtle cues.
“If it’s a very noisy room, you can definitely miss that something was given or not given, and you can make assumptions. I’ve certainly made lots of assumptions over time that because they ordered something, something got given and then eight hours later you find out that that never happened. So, constantly worried that I’m missing something.” [7]
“It’s hard over the video camera to get the subtly of the body cues or non-verbal cues from the rest of the team, from the patient, from the care givers that maybe also there in the room.” [9]
Most coordinators mentioned that despite not knowing the rural team, they generally trust the information being provided. However, if they perceive that they are supporting a junior or inexperienced team, their scepticism increases.
“When [coordinators are] dealing with people that they are not familiar with, there may be that sort of trust, ‘is this the right information?’ But I've been doing that for a long time now that I'm used to [it], so there are some things that you just have to let go and you go, ‘this is what they're telling me, I have to trust that they're telling me that’.” [1]
“You've got to understand who's telling you and their clinical experience…You're more hands on or more sceptical of what you're being told by less experienced people.” [6]
Not knowing the local facility also means that coordinators are unaware of the broader context they are dialling in to, such as prioritisation of patients and other demands. Some coordinators reported that this lack of awareness affects their ability to guide the rural team appropriately, whereas others felt it not necessary to know everything going on in the rural facility.
“I think there was other things going on in the clinic there at the time. I wasn’t particular privy to that…It's just a limitation of the technology, and it probably always should be, that you can't see everything that’s going on.” [1]
“This is a pinhole. I'm looking at a certain patient in a certain bed with fixed cameras, but I don't know what else is going on in the room…I don't know if there is a whole tribe of people at the door trying to get in and see someone. Whether they love them or want to murder them.” [5]
With emergency videoconferencing systems installed in over 110 rural facilities, it is not currently possible for coordinators to know each facility’s unique capacity and capability. However, without this knowledge, and without any established relationships with the rural clinicians, it can be difficult to gauge the level of support required, the kinds of procedures that are possible, and the competing demands in the rural facility.
2.0 How telehealth technology facilitates or limits emergency support
2.1 Establishing and maintaining awareness of the rural situation. Several factors impact a coordinator’s ability to establish and maintain awareness during an emergency telehealth videoconference, and coordinators employ several strategies to improve their awareness. One of the strategies discussed by several coordinators was to collect as much information as possible from the rural team before the videoconference has begun.
“Don't let them put the phone down. While we're setting up, can you just give me a verbal brief on what it is?” [5]
“If it's not an immediate, time-critical thing and they're asking for some nuanced clinical advice, then you can sort of offload a bit of the work of the telehealth and the information finding by getting that organised for you prior. By one of the RSQ clinical nurses, for example.” [6]
Then, during the videoconference, coordinators primarily use the visual modality to collect information about the patient, rural team, and facility. Some coordinators described this as collecting ‘the ground truth’ about a patient’s state. The visual component of the videoconference also allows coordinators to view the resources in the rural facility, including staffing levels and available equipment. One participant recalled a situation where viewing the room allowed them to find key equipment in the resuscitation bay and instruct the rural team on how to use it.
“So, I ring up, and here’s this bloke on oxygen not doing very well. So, he needs some invasive respiratory support. So, I say, ‘look, can you put him on CPAP?’ The answer is, ‘no, we can’t because we don’t have a machine for that’. You know, if – down the phone, that starts and ends there. So, ‘hold on a sec, I can see an Oxylog 3000 in the back of your room. Your ventilator can do CPAP.’ ‘Oh, yeah, we don’t know how to use it.’ ‘That’s fine. Bring it over here. Put it down there, and I will talk you through it.’…‘We don’t have a mask.’ ‘Why don’t you call your local ambulance and get them up? Because they carry the masks.’…So, we’ve got the mask, but it’s designed to be plugged into five-millimetre oxygen tubing, not a ventilator circuit. So, ‘well, hold that up. Yep, you should just be able to pull that out and plug the ventilator’. ‘Yep, we can do that’…So, now we’ve got the ventilator, the circuit, and the mask. We can put it on the patient, and I can talk you through that. We’d sort of gone from, oh, waving a laryngoscope around going, ‘oh shit, we’ve got to intubate this patient, so it’s a complete disaster’, to ‘okay, well now we’ve actually got a plan to save the patient’s life while we come up with the next step.” [2]
This example demonstrates how telehealth can be used to support resource-gathering in addition to decision-making and communication. Coordinators generally feel that the advantage of videoconferencing is that they can collect this kind of information firsthand, providing a significant advantage over a phone consultation. Telehealth allows coordinators to confirm or refute verbal information, such as verifying handover information provided prior to the telehealth session, which can be less distracting and intrusive for the rural team. Several coordinators recounted stories where the visual input showed a less critical situation than was described to them over the phone, which, in some cases, prevented an unnecessary retrieval. There were also scenarios where concern increased due to the visual input, changing the treatment and management.
“You also work out I guess little heuristics or whatever when you say, ‘oh, they're saying this’, but I can see other things that make me think that that’s not what's going on. But that’s not because of anything deliberate on their behalf, that’s just I guess your clinical acumen as you become more experienced to go, ‘well, this doesn’t fit. So what else is causing that’.” [1]
“The ‘end-of-the-bed’ogram’ is really going to help me here because I’m not going to have to ask you a million questions.” [7]
“When you have a description from a doctor on the phone and then you go and turn on the telehealth, a picture paints a 1000 words. So sometimes someone can sound okay and then you go and switch on telehealth and you look at them and you just think that - even though you can’t put it into words, that patient just looks rubbish and your level of concern goes up and it changes how we manage things.” [8]
The telehealth system was praised by most coordinators, providing a good overall picture and allowing them to zoom in to see fine-grained details.
“The resolution is quite amazing…You can zoom in across the room onto a monitor that’s smaller than a laptop screen and be able to see things clearly enough to make a diagnosis off that.” [1]
“The pictures we get now are phenomenal, the depth you get, the quality, the zoom in and zoom out are just amazing.” [3]
As a result, coordinators generally report that the telehealth system enables them to obtain high-quality visual information. However, half of the participants recalled scenarios where they felt limited by the fixed cameras. Chest drains were a common example of a procedure where it is difficult to provide nuanced guidance with a fixed camera system.
“One is chest drains. It's quite hard [with] the fixed system…How am I going to do that? How would I do that if I'm instructing my senior registrar or registrar here? I'm not going to stand on a stepladder at the back of the room. Where I would actually like to be is standing just behind your shoulder.” [5]
“The lighting [the local doctor] needed to give her a good view provided a lot of glare on the TV screen, so I struggled to see the incision that she was making, and the size. Also, the angle of the chest tube insertion, it was difficult to see where it was going, I just couldn’t make out the angles with the way that our camera was…I think that’s why the chest tube ended up in the wrong place.” [8]
Some coordinators described feeling constrained by the image they receive through telehealth and how it differs from being there in person, with one common example being when rural clinicians unknowingly block their view.
“In certain views people are just constantly standing in front of the monitoring equipment, and things like that.” [7]
“You can’t see 3D, that’s the problem...There’s a lot that you gain just by standing at the end of a patient’s bed and just looking at a patient. You don’t get - it’s not quite the same when you’re looking on telehealth on a camera.” [8]
“Because all said and done, the telehealth is still a 2D image. Although it’s technically in 3D, you’re still relying on the clinician there to relay pretty much everything.” [10]
Although the visual modality is very important for coordinators to establish and maintain awareness, it does not remove the importance of good verbal communication, especially in those situations where the view is limited.
“[The local doctor] articulated what was happening, which is really useful to the whole team, but particularly when you’re on VC and you can’t grab a bit of paper and have a look yourself…He’d get a gas back and he’d [give] dot points of what was on the gas. So, I could make little notes of what was happening without interrupting and asking questions.” [7]
“I couldn’t see physically myself what the position of the tube and what the drain was doing, what the underwater seal was doing, was it bubbling, swinging, that sort of thing. So, I couldn’t appreciate those things myself…You just have to rely on somebody telling you that and you’re not sure whether they’re seeing what you would be expecting to see. So, I think the communication is really important.” [8]
Some coordinators noted that the system does not allow them to view multiple camera feeds simultaneously, meaning that they frequently switch back and forth between cameras.
“[The camera is] on the roof so if you want to have bird’s eye, you can have bird’s eye and everything but then everything’s just really small and you can't see the patient's work of breathing or the colour that well. Most times I’ll either zoom into the patient and then episodically move to the vital signs.” [9]
“It’s like looking at something that’s happening in the distance. I don’t feel that I’m fully aware, because you only have a small part of the room. So, you are either visualising the patient or the monitor, or the clinician.” [10]
Additionally, the functionality and usability of the system can worsen depending on who is controlling the cameras and who has initiated the videoconference. For those working in the northern hub, there can be inefficiencies if a RSQ nurse is operating the cameras from the southern hub.
“It can be a little bit difficult to operate the system in terms of switching between cameras and driving them remotely…If someone drives it from the centre in [Brisbane], they drive it better, but I have to tell them where to drive, which is the trade-off.” [2]
“We find it quite difficult when people ring us, rather than us ringing them, which is easier because it means we can then manipulate the cameras. So, I think people sometimes in a panic dial us, as opposed to us dialling in and it just gives us that added difficulty of not being able to manoeuvre the cameras.” [4]
“I quite like getting the nursing staff from Retrieval Services bringing us into the VC consults, but surprisingly that can be really frustrating because they’re in a separate room down in Brisbane and we’re up in Townsville. They can just suddenly decide that I might want to look at the monitor when I actually want to look at the patient, and unfortunately that means, I have to speak into that [rural] room for the [RSQ] nurse to hear me.” [7]
Coordinators heavily rely on the visual component of the videoconference to obtain information and maintain awareness of the rural situation. The ability to collect firsthand information allows coordinators to confirm or refute verbal information, and can reduce the need to interrupt rural clinicians. When the visual input is limited (for example, because of the fixed camera system, or when the cameras are controlled by others), coordinators can struggle to maintain awareness and therefore provide tailored support.
2.2 Supporting rural teams from a distance. Despite sometimes feeling a sense of helplessness when providing support from a distance, coordinators perceived that the facilitation of rapport and relationship building is one of the biggest advantages of telehealth. Several coordinators noted that the two-way video feed amplifies the emotional aspect and importantly, it allows the rural team to see who is supporting them.
“The thing is that the visual thing does bring the emotional aspect into the room. It's something you face with. Not something you hear.” [5]
“I think much more useful is that people put a face to the voice. So, from our perspective to be able to see a face to build the relationship both with the team and the care givers in the room as opposed to this anonymous voice making decisions.” [9]
To facilitate rapport building and expectation setting, coordinators often adopt an inquisitive communication style by asking the rural team what is required of them up front, rather than assuming what they want help with.
“I suppose the trick in that is about the communication stuff that you do, the non-technology stuff of tailoring it in the right way to value add the best. A part of that is at the beginning saying, ‘well, I was going to do this, are you happy with that? How do you want me to contribute towards this?’ It’s almost having some ground rules there.” [3]
“My practice I guess progressed, changed slightly over the years and often [I] just open up with ‘how do you want me to help?’ which is slightly different to my role in the emergency department where I’m automatically, you know, usually a team leader.” [9]
Several coordinators mentioned that sometimes they can feel as though they are not contributing much to the treatment or management of the patient. However, telehealth allows them to provide peer support to rural teams and reduce their professional isolation, which seemingly adds more value to the situation than the clinical input it is intended to provide.
“We might have helped [avoid a retrieval] in a couple, but it wasn’t a big driver. We actually found that the benefits that we got out of that were that the clinicians felt much more supported…The ones that were scared felt infinitely supported in telehealth.” [3]
“I think they were very relieved to have us there…It just didn’t really feel like we did much effective except stare at everybody.” [7]
“Most times I feel the main benefit is of supporting the rural teams. Probably that main benefit I suspect and the second one is giving good patient care, more timely patient care…Most times I’m supporting the team.” [9]
Coordinators are often sought for reassurance that the team has provided the best level of care possible given the circumstances, and their presence in the room (albeit virtually) is especially important when patient outcomes are poor.
“The feedback was that they just found that it [was] reassuring but it was that support that they got, they just thought it was brilliant. It reinforced to them why they’ve got [telehealth] and to us it reinforced, God, we’ve actually value add.” [3]
“You don’t realise how valuable it is for them. To say, ‘we’ve done all of this’, and we say, ‘there is nothing else to do. You’ve done everything’.” [7]
Another commonly noted form of peer support is sharing the mental load with the rural team because they are often working with minimal staff. As an objective party, coordinators also facilitate shared decision making which can be difficult for rural teams to make on their own because of their community ties.
“I think having someone else participating in the discussion around of saying, ‘let’s stop’ and helping with those end-of-life discussions is very powerful as well. You’re the doc there and you live there, and you’ve got to face the family and these people – the family will know that every effort was made, they’ve accessed someone from wherever who’s come in, they’ve helped make the decision. So, turning someone off and not progressing is a big call and I think it allows us to participate in those.” [3]
“They were crashing and becoming hypoxic post-intubation and I had to more or less do the cognitive thinking and the troubleshooting for that and provide direct instructions, which I wouldn't have been able to do without seeing the patient.” [6]
Some coordinators recalled situations where they relieved some of the rural burden by speaking directly to patients and families on behalf of the team. In some cases, they may retrieve a patient even when it will not change the patient’s outcome, primarily to support the rural team who does not have capacity to manage them.
“You can actually have a discussion with the family about the pros and cons of treatment. You can’t touch them, you’re not physically there, but it still allows you to still have that verbal and non-verbal interaction with the family about making some decisions.” [3]
“My primary conversation was with the nurse and then with the [patient’s] parents…We just have to get the kid out, because of the parental concern and anxiety, and also to support the nurse, there, I think it was the sole nurse in the community.” [10]
In addition to peer support, the telehealth system also allows coordinators to provide value in other ways, for example by remotely guiding rural teams through uncommon procedures, the operation of rarely-used equipment, and the delivery of medications that would otherwise not be possible.
“I asked the intensive care paramedic to come out and intubate the patient. So, to intubate this patient, we needed to administer paralytics – muscle relaxant agents – which paramedics aren’t allowed to do. So, I sort of said, at the time, ‘look, I’m happy, I mean, I’m not in the room, but I am running this case, and I’m happy - my name is in the notes, there’s a clear verbal or a written’, and then off we went.” [2]
“She needed escharotomy. That was done on the basis of visual approach and some instruction given…Which is not a common surgical technique…That's limb saving.” [5]
“I think being able to see what she was looking at, she could pick something up and say, ‘this bit? What do you want me to do with this bit?’ Then I could say, ‘no, turn it around, you use it the other way’.” [8]
Many coordinators believed that providing emergency telehealth support, whether that be peer or clinical support, is a specialised skillset different to face-to-face support and phone consultations.
“This I find is a much more dedicated event…It's a challenge sometimes. It's a modified skillset.” [5]
“I think you can underestimate the skill that’s required to get good at doing these things. Because you think, well I can do it in person, I should be able to do it over a video link. But you’re relying on somebody else being your hands essentially…It’s a big learning curve.” [8]
However, not all discussions or tasks are deemed suitable to the videoconference modality. For example, coordinators are sensitive to rural clinicians’ positions within their community, and may offer to discuss sensitive topics on a private phone call away from patients and family. Debriefing was another task deemed unsuitable for telehealth, but something that coordinators often wish to be involved in to provide follow up support.
“Sometimes people use telemedicine to do a debrief. The problem is it's all hardwired. You have got to go to the resus bay. Actually, that's probably not the best room. The body is still probably in there.” [5]
“We discussed [the procedure] behind the scenes away from the patient so that it didn’t alarm the patient talking about those things and didn’t undermine the patient’s confidence in the doctor…Also, the doctor might feel pressured into saying ‘yes I can do it’, if they’ve got people watching. So, I think to give them the freedom to say privately, ‘look I haven’t done this on my own before, I don’t feel confident’, I think is important.” [8]
Most coordinators agreed that simply being present during a rural resuscitation can have a significant, positive impact on the treating team. Coordinators believed that their biggest contribution is not necessarily their specialised knowledge and experience, but rather the peer support they provide during acute cases. The bidirectional telehealth system facilitates rapport building and allows coordinators to provide other forms of peer support such as speaking to patient relatives on the team’s behalf. However, the system does not support all interactions, such as those requiring privacy or debriefing events.
2.3 Working within the constraints of local capacity and capability. Although it can be challenging to gauge the rural situation over telehealth, coordinators agree that knowledge of the rural team, patient state, and resources available is important to optimise the quality of support they provide. Several coordinators noted the importance of understanding the confidence and competence of the rural clinicians, since this will heavily inform the guidance they provide. For example, coordinators tend to take a conservative approach to procedures and will avoid those beyond the rural team’s skillset. Intubation was common example of a procedure that coordinators avoid when supporting inexperienced or unconfident staff. To obtain this information, coordinators can simply ask the clinicians but they may feel pressured to conceal the truth, especially with relatives or other staff present. Therefore, coordinators use telehealth to observe their behaviour and non-verbal cues, such as facial expressions and how they handle equipment.
“Someone wants to [intubate] – ‘yes, we can intubate’. Okay. You watch them put the equipment together. They're not familiar…If I watch how people handle equipment, yes there is anxiety and things. But it tells me [a lot].” [5]
“This has happened on a few occasions where I’ve said, ‘are you comfortable intubating?’…Then they say, ‘well if it gets to it, then I can do it’. That tells me that they probably haven’t done it often enough, but they’re going to give it a shot. This is probably where I would probably not get them to do it, unless [the patient] start going blue in the face.” [10]
Further, coordinators use the visual modality to tailor their roles and tasks to best suit the rural situation. For example, coordinators are careful not to overstep when they are supporting more experienced clinicians, or provide support that is too high level for less experienced staff who need intricate guidance. All coordinators agreed that they most commonly adopt the team leader role during critical situations, especially in nurse-led facilities with no local doctor.
“I think that’s a bit of emotional intelligence there in terms of how you insert yourself into the proceedings…Where there’s a number of senior staff there, I think you’ve got to be very careful that you’re not then overstepping it. There’s that more collegiate, respectful thing that they’re running it but you’re there to maybe help them troubleshoot or value add if they get into trouble or help with some decision-making.” [3]
“The team leader, who was the senior most clinician doctor there, was in control of the situation. Making sure that all team members were performing to their optimal extent, and I was almost a passive observer and only responded to questions that the team leader had.” [10]
The telehealth technology also allows coordinators to provide situation awareness to the local team because they have a birds-eye view and are not preoccupied with their own tasks. This keeps the local team on track and allows them to focus on their manual tasks.
“They mostly found it good to have someone watching over and having that external oversight and guidance. They did all the hard work really, I was just able to say, ‘right, so we need to - this is the next step we need to do. We need to do that now, okay, it looks like you're bagging well.’” [1]
“All the nurses in the hospital were there helping out and then that one doctor’s doing the intubation, it’s often helpful to have somebody else that can manage the medication, they can keep an eye on the vital signs and the other aspects of it.” [9]
Some coordinators were conscious of the delicate balance between providing support and being a distraction, and felt that the visual input was helpful to inform when they ask questions or provide instructions.
“In a resus here I would maybe say three or four drugs at the same time, that I want the patient to have, but just sort of taking that step back and slowing things down for small facilities that don’t do this often and potentially only have one, maybe two nurses.” [4]
“I find [cardiac arrest] most challenging of all telehealth interactions, simply because you are trying to provide support, but you cannot interfere with the running of the cardiac arrest itself.” [7]
To provide tailored clinical support, some coordinators recalled situations where they added other specialists into the videoconference for more specialised advice, such as in burns or paediatric cases. This was a well-regarded feature of the telehealth system that allowed rural clinicians to seamlessly connect with metropolitan specialists.
“She proved really difficult to ventilate and I was maxing out my skills and knowledge so we also got an intensivist who was on call for ECMO at that time to dial in and provide some ventilatory support…I think it actually worked pretty well and it was good to also, pretty seamlessly, be able to dial in that extra support.” [6]
“I’ve probably done this on one occasion, where I’ve got a paediatric intensivist…Which has been fantastic, because then they actually have seen the patient and they have brought their expertise to the patient bedside, to a patient who is four hours away.” [10]
To ensure that the rural team feels fully supported, coordinators can use telehealth to virtually ‘stay’ with the rural team until the retrieval team arrives and assist the rural team in the patient handover if needed.
“So, the other thing that we find it very useful for is, is handovers…As a [retrieval] team gets there, the process is that when they get there, they have a look at the patient and before they leave will chat with us as the consultant to be sure everything’s kosher, and they’ve got a plan and all that sort of stuff.” [3]
“Then you might still leave the telehealth running in the background, intermittently being monitored by a [RSQ] nurse, but your focus is away while that patient is stable and then you'll get called in for further updates or advice as required.” [6]
Coordinators were asked hypothetical questions about whether they could still provide support if telehealth was not available in the memorable events they recalled. Overwhelmingly, they felt that it would have been much more difficult and that emergency telehealth support led to better patient outcomes.
“I think that the patient would have died much more incipiently probably – not quite through medical misadventure but because of medical limitations on the nature of the care that could have been provided without the telehealth.” [2]
Coordinators use telehealth to directly observe the patient condition, team composition, and resources available, which subsequently informs the kind of support they provide. Coordinators typically adopt a team leader role but may adapt their role to suit the specific team and context. The telehealth technology allows coordinators to keep situation awareness, to determine the right moments to speak, to bring other specialists into the scenario, and to assist in patient handovers. Without the telehealth technology, coordinators believed that patient outcomes would be worse and rural clinicians would be less supported.