The project involved two phases:
Phase 1 – (12 months, from October 2015 to October 2016) – The pilot and evaluation phase, included establishing the video-conferencing between the FM centre and the obstetric unit, the advanced training of sonographers and collection of participant questionnaire data. Patient experience data was collected throughout the initial 12 month, funded set-up phase (2015–2016).
Phase 2 (36 months, from November 2016 to October 2019) – The embedding and adoption phase, which involved increasing complexity of cases and the introduction of multidisciplinary consultations.
The service was implemented at a specialist FM centre in North East England, and an obstetric unit situated in the North West of England (~ 1,200 births per annum) in October 2015. The service utilised existing 2 × 100Mbp/s fibre optic circuits, installed between the hospitals during the pilot phase of the project to support another clinical service. A codec was installed at both sites together with a Cisco Video Conferencing (VC) unit at the FM centre and a Polycom Group 500 VC unit at the obstetric unit to allow the handling of high quality images using the least bandwidth. A bespoke unit including a monitor, microphone, camera and codec was assembled for use in the clinical ultrasound room. The camera position could be switched (using a remote control) between the ultrasound machine display during scans, to the woman and her family during pre- and post-scan counselling. The FM consultant and the family had a full screen view of each other when discussing the scan findings.
Information Technology (IT) support was provided by a 24-hour help desk at the FM centre and by the local IT team at the obstetric unit. The telemedicine link was available for one session (~ 3 hours) per week requiring the provision of an obstetric sonographer. A midwife was present throughout the consultation to provide support to the woman and family at the obstetric unit.
Referrals from the obstetric unit for FM opinion were assessed for telemedicine suitability by one of the FM consultants or the lead FM midwife. All appropriate cases were offered telemedicine consultation; cases were excluded from telemedicine consultation for the following reasons: (a) anticipated need for invasive diagnostic or therapeutic intervention (b) structural cardiac anomaly [due to presence of separate fetal cardiology clinics] (c) suspected facial clefts [due to the need for 3D ultrasound]. Measurement of nuchal translucency (as part of combined testing for common trisomies in twin pregnancies), previously undertaken at the FM centre, was introduced in June 2016 with scans being viewed by an experienced midwife sonographer. An information sheet, as well as verbal explanation of the process was provided to women prior to the telemedicine consultation. Standard operating procedures were issued to staff, which included guidance on the equipment set-up, patient referral and suitability assessment, consultation process and action in case of link failure.
Three experienced sonographers, each with over eight years’ obstetric ultrasound experience, completed a training programme during the first four weeks of the pilot phase of the project. The sonographers familiarised themselves with the teleconferencing equipment while undertaking fetal growth scans, supported by the team at the FM centre. This provided the opportunity to test the quality and reliability of the transmitted audio and ultrasound images and to undertake training in the acquisition and interpretation of uterine artery (UAD) and middle cerebral artery (MCAD) Doppler. Sonographers at the obstetric unit did not perform UAD or MCAD prior to the implementation of the telemedicine link and women were previously referred to the FM centre if these investigations were indicated. The sonographers were provided with a pre-training manual and remote guidance via the telemedicine link from an experienced midwife sonographer based at the FM centre.
Ultrasound scans at the obstetric unit were performed ), using a Toshiba Aplio 400 ultrasound machine. During the ultrasound consultation, a FM consultant provided verbal guidance to the sonographer via the telemedicine link to ensure that the necessary images and measurements were obtained. Following the scan, the FM consultant discussed the findings and implications with the woman and her partner/supporting person. A scan report was sent to the referring clinician via a secure email service (NHS Mail) immediately following the telemedicine consultation.
Sonographers completed a training programme during the first four weeks of the pilot phase of the project. The sonographers familiarised themselves with the teleconferencing equipment while undertaking fetal growth scans, supported by the team at the FM centre. This provided the opportunity to test the quality and reliability of the transmitted audio and ultrasound images and to undertake training in the acquisition and interpretation of uterine artery (UAD) and middle cerebral artery (MCAD) Doppler. Sonographers at the obstetric unit did not perform UAD or MCAD prior to the implementation of the telemedicine link and women were previously referred to the FM centre if these investigations were indicated. The sonographers were provided with a pre-training manual and remote guidance via the telemedicine link from an experienced midwife sonographer based at the FM centre.
All women undergoing their first telemedicine appointment during pilot of the project were invited to complete a questionnaire following their consultation. The aim was to evaluate respondent’s perceptions of the experience of the consultation, including whether they felt involved in their care, knew who to contact with concerns and whether they would choose to use a telemedicine consultation in the future. The questions were based on items used in a previous study (13) and responses were recorded using a five-point Likert scale. Respondents were asked to record the actual costs incurred to attend the telemedicine appointment (for example, travel and childcare costs) and estimated costs of travel and other associated expenses to the FM centre (supplementary file 1). The FM consultants completed a Likert-scale to assess the quality of the image and audio for both the ultrasound scan and subsequent discussion following each consultation. Descriptive analysis of data was performed using SPSS version 21.0 for Windows.